MEDICARE: DR. DARREN ROBERT BLOM O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC2976	FL

General Provider Information

NPI Number	:	1902930605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DARREN ROBERT BLOM O.D.

Provider Business Mailing Address
First Line	:	3801 W GLENDALE CT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32259-4527
Country	:	US
Telephone Number	:	904-287-0096
Fax Number	:

Provider Business Practice Location Address
First Line	:	7205 BONNEVAL RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-7565
Country	:	US
Telephone Number	:	904-696-9486
Fax Number	:	904-696-3422

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	02/22/2010

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