Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | 01068126A | IN |
N | 208600000X | Surgeon | 01068126A | IN |
Y | 2086S0122X | Plastic and Reconstructive Surgery | 01068126A | IN |
NPI | 1144488495 |
---|---|
Provider Name | Jason Matthew Blocksom |
First Address | Indianapolis, IN 46290-1024 |
Second Address | Indianapolis, IN 46260-2074 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2008 |
Last Update Date | 20/09/2021 |