Provider Demographics
NPI:1831197276
Name:BLUME, JAMES ERVIN (OD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ERVIN
Last Name:BLUME
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5917 STONEY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-4401
Mailing Address - Country:US
Mailing Address - Phone:260-482-8435
Mailing Address - Fax:
Practice Address - Street 1:5917 STONEY CREEK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-4401
Practice Address - Country:US
Practice Address - Phone:260-482-8435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2009-02-11
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
IN18001661B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100385090AMedicaid
4164020001OtherNATIONAL SUPPLIER CLEARINGHOUSE
IN100385090AMedicaid
IN138560Medicare PIN