Provider Demographics
NPI:1144750035
Name:BLOOM, TANYA SARAH (OD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:SARAH
Last Name:BLOOM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 N AURORA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4202
Mailing Address - Country:US
Mailing Address - Phone:607-277-4749
Mailing Address - Fax:
Practice Address - Street 1:322 N AURORA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4202
Practice Address - Country:US
Practice Address - Phone:607-277-4749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008632152W00000X
CT3039152W00000X, 152WV0400X
NY8632152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist