Provider Demographics
NPI:1902930605
Name:BLOM, DARREN ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:DARREN
Middle Name:ROBERT
Last Name:BLOM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3801 W GLENDALE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4527
Mailing Address - Country:US
Mailing Address - Phone:904-287-0096
Mailing Address - Fax:
Practice Address - Street 1:7205 BONNEVAL RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7565
Practice Address - Country:US
Practice Address - Phone:904-696-9486
Practice Address - Fax:904-696-3422
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2976152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV04225Medicare UPIN