Provider Demographics
NPI:1538382528
Name:BLOMSTEDT, JOHN E III (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:BLOMSTEDT
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 W 42ND ST STE 3500
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4669
Mailing Address - Country:US
Mailing Address - Phone:308-630-2595
Mailing Address - Fax:308-630-2596
Practice Address - Street 1:2 W 42ND ST STE 3500
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4669
Practice Address - Country:US
Practice Address - Phone:308-630-2595
Practice Address - Fax:308-630-2596
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE724207Q00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200913070Medicaid
738460UUUUMedicare PIN