Provider Demographics
NPI:1396777124
Name:DEBLOOM, JAMES R II (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:R
Last Name:DEBLOOM
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ASHBY PARK LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6903
Mailing Address - Country:US
Mailing Address - Phone:864-288-1154
Mailing Address - Fax:864-288-2554
Practice Address - Street 1:300 ASHBY PARK LANE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6903
Practice Address - Country:US
Practice Address - Phone:864-288-1154
Practice Address - Fax:864-288-2554
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL28759207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCID287594Medicaid
SCAA15338573Medicare PIN
SCI61392Medicare UPIN
SCID287594Medicaid