Provider Demographics
NPI:1023399177
Name:BLOOM, KENNETH JOEL (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOEL
Last Name:BLOOM
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 1:31 COLUMBIA
Mailing Address - Street 2:CPS
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1460
Mailing Address - Country:US
Mailing Address - Phone:949-425-5744
Mailing Address - Fax:949-425-5865
Practice Address - Street 1:31 COLUMBIA
Practice Address - Street 2:CPS
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-1460
Practice Address - Country:US
Practice Address - Phone:949-425-5744
Practice Address - Fax:949-425-5865
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86592207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology