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General NPI Number Information
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NPI Number | 1801336995
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Entity Type | Individual
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Provider Name | MARK BLOMBERG D.O.
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Gender | Male
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Dates
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Enumeration Date | 03/08/2017
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Last Update Date | 12/18/2020
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Provider Practice Location Address
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Address Line | 400 S CENTER ST
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City | DURAND
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State | IL
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Zip | 61024-9590
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Country | US
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Telephone | 815-248-3443
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Fax |
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Provider Business Mailing Address
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Address Line | 515 22ND AVE
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City | MONROE
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State | WI
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Zip | 53566-1569
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Country | US
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Telephone | 608-324-1518
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 71267
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License Number State | WI
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