Provider Demographics
NPI:1760642771
Name:BLUM, ANDREW R (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:R
Last Name:BLUM
Suffix:
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 1:701 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3236
Practice Address - Country:US
Practice Address - Phone:386-943-3160
Practice Address - Fax:317-705-5047
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4285782085R0202X
FLME1359512085R0202X
MA2349642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100042500Medicaid