Individual
LEE CHARLES BLOEMENDAL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1325 PENNSYLVANIA AVE, SUITE 720, FORT WORTH, TX 76104-2144
(817) 336-7305
(817) 336-8941
Mailing address
PO BOX 961205, FORT WORTH, TX 76161-1205
(817) 740-8400
(817) 336-8941
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
D5919
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
020054578
RAILROAD MEDICARE
—
05
—
032314902
—
TX
Enumeration date
07/13/2006
Last updated
10/04/2011
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