Provider Demographics
NPI:1164482949
Name:BLOOM, TAMMY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:LEE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-397-4040
Mailing Address - Fax:360-604-1770
Practice Address - Street 1:2525 NE 139TH ST STE 220
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-397-4437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37480-020208800000X
WAMD60525316208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology