Provider Demographics
NPI:1144400763
Name:BLOOM, LARRY MARTIN (OD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:MARTIN
Last Name:BLOOM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2731
Mailing Address - Country:US
Mailing Address - Phone:419-882-8467
Mailing Address - Fax:419-882-8951
Practice Address - Street 1:5600 MONROE ST
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560
Practice Address - Country:US
Practice Address - Phone:419-882-8467
Practice Address - Fax:419-882-8951
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2757/T1242152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0465262Medicare PIN
OH0516880001Medicare NSC