Provider Demographics
NPI:1194925024
Name:BLOME, DEXTER W (MD, PHD)
Entity type:Individual
Prefix:
First Name:DEXTER
Middle Name:W
Last Name:BLOME
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 MCNAUGHTEN RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2174
Mailing Address - Country:US
Mailing Address - Phone:614-755-4155
Mailing Address - Fax:614-755-5104
Practice Address - Street 1:85 MCNAUGHTEN RD
Practice Address - Street 2:SUITE 260
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2174
Practice Address - Country:US
Practice Address - Phone:614-755-4155
Practice Address - Fax:614-755-5104
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.061691208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery