=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316099088
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT M BLUM O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 06/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1757 E WEST CONNECTOR STE 400
-----------------------------------------------------
City | AUSTELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30106-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-941-4445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 484 LANCASHIRE DR
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30068-4275
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-457-0843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1072
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------