Provider Demographics
NPI:1275805848
Name:BLOOM, LAWRENCE MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:MICHAEL
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 1:517 PARK ST
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1963
Mailing Address - Country:US
Mailing Address - Phone:973-746-0447
Mailing Address - Fax:
Practice Address - Street 1:31 WASHINGTION SQUARE WEST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-0000
Practice Address - Country:US
Practice Address - Phone:973-746-0447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0967331174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist