Provider Demographics
NPI:1225005879
Name:BLOOM, R. LAMONT (MD)
Entity Type:Individual
Prefix:DR
First Name:R.
Middle Name:LAMONT
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 1:406 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-1058
Mailing Address - Country:US
Mailing Address - Phone:316-265-0705
Mailing Address - Fax:316-265-0785
Practice Address - Street 1:406 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-1058
Practice Address - Country:US
Practice Address - Phone:316-265-0705
Practice Address - Fax:316-265-0785
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-18702207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100195740AMedicaid
KS002495Medicare PIN
KS100195740AMedicaid