Provider Demographics
NPI:1316099088
Name:BLUM, ROBERT M (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:M
Last Name:BLUM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:484 LANCASHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-4275
Mailing Address - Country:US
Mailing Address - Phone:678-457-0843
Mailing Address - Fax:
Practice Address - Street 1:1757 E WEST CONNECTOR STE 400
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1248
Practice Address - Country:US
Practice Address - Phone:770-941-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1072152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCFZSMedicare ID - Type Unspecified
GAU21165Medicare UPIN