Provider Demographics
NPI:1275541815
Name:BLOOM, BONNIE (OD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:
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 1:1422 N LOOP 336 W
Mailing Address - Street 2:SUITE B
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3540
Mailing Address - Country:US
Mailing Address - Phone:936-539-2020
Mailing Address - Fax:936-756-7916
Practice Address - Street 1:1422 N LOOP 336 W
Practice Address - Street 2:SUITE B
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3540
Practice Address - Country:US
Practice Address - Phone:936-539-2020
Practice Address - Fax:936-756-7916
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6812152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU35171Medicare UPIN
VA9314-0009OtherCAREFIRST
VA104891OtherANTHEM BCBS -ALEX
VA011324N11Medicare ID - Type Unspecified