Provider Demographics
NPI:1326290594
Name:DR BLOOMBERG EYE CLINIC
Entity Type:Organization
Organization Name:DR BLOOMBERG EYE CLINIC
Other - Org Name:BLOOMBERG EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLOOMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-758-6671
Mailing Address - Street 1:1449 BOARDMAN CANFIELD RD
Mailing Address - Street 2:STE 230
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-8053
Mailing Address - Country:US
Mailing Address - Phone:330-758-6671
Mailing Address - Fax:330-758-1451
Practice Address - Street 1:1449 BOARDMAN CANFIELD RD
Practice Address - Street 2:STE 230
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-8053
Practice Address - Country:US
Practice Address - Phone:330-758-6671
Practice Address - Fax:330-758-1451
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR BLOOMBERG EYE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-19
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4008/T-032152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0754045Medicaid
OH770910Medicaid