Provider Demographics
NPI:1093774556
Name:BLOOM, CYNTHIA R (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:R
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 UNIVERSITY SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5513
Mailing Address - Country:US
Mailing Address - Phone:813-253-2721
Mailing Address - Fax:813-253-2299
Practice Address - Street 1:1700 SOUTH TAMIAMI TRAIL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239
Practice Address - Country:US
Practice Address - Phone:941-917-1668
Practice Address - Fax:941-917-4273
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME732652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL41300OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL252222500Medicaid
FL41300OtherBLUE CROSS BLUE SHIELD OF FLORIDA
FL41300YMedicare ID - Type Unspecified
FL252222500Medicaid
FL41300RMedicare PIN