# JOHANNES V. BLOM, MD, PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1932410008
- **Authorized official:** MRS. GABRIELA ENGELS (ADMINISTRATOR)
- **Authorized official phone:** (954) 964-6114

## Contact information

- **Practice address:** 300 SE 17TH ST, 2ND FLOOR, FT LAUDERDALE, FL 33316-2550
- **Practice address phone:** (954) 964-6114
- **Mailing address:** 300 SE 17TH ST, 2ND FLOOR, FT LAUDERDALE, FL 33316-2550
- **Mailing address phone:** (954) 964-6114

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207X00000X | Orthopaedic Surgery Physician | ME94285 | FL | Yes |
| 207XS0114X | Adult Reconstructive Orthopaedic Surgery Physician | ME94285 | FL | — |
| 207XX0005X | Sports Medicine (Orthopaedic Surgery) Physician | ME94285 | FL | — |
| 207XX0801X | Orthopaedic Trauma Physician | ME94285 | FL | — |

## Other

- **Enumeration date:** 06/23/2010
- **Last updated:** 06/23/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1184654519 | PROVIDER NPI | FL |
| 05 | — | 275038400 | — | FL |