Provider Demographics
NPI:1225028590
Name:BLOOM, MARVIN E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:E
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 1:4013 N CHESTERBROOK RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207-4635
Mailing Address - Country:US
Mailing Address - Phone:703-696-7935
Mailing Address - Fax:
Practice Address - Street 1:450 CARPENTER RD
Practice Address - Street 2:RADER CLINIC
Practice Address - City:FT MYER
Practice Address - State:VA
Practice Address - Zip Code:22211-1008
Practice Address - Country:US
Practice Address - Phone:703-696-7935
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101020307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine