Provider Demographics
NPI:1922082965
Name:BLUM, MICHAEL A (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:BLUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:579 NW LAKE WHITNEY PLACE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1622
Mailing Address - Country:US
Mailing Address - Phone:772-249-0260
Mailing Address - Fax:772-249-0137
Practice Address - Street 1:579 NW LAKE WHITNEY PLACE
Practice Address - Street 2:SUITE 101
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1622
Practice Address - Country:US
Practice Address - Phone:772-249-0260
Practice Address - Fax:772-249-0137
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS0007680207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261284400Medicaid
FLE4377Medicare PIN
FL261284400Medicaid