Provider Demographics
NPI:1336468461
Name:BLOOM, DAVID A (MD, PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 66TH N ST
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-5040
Mailing Address - Country:US
Mailing Address - Phone:727-343-0600
Mailing Address - Fax:727-344-6163
Practice Address - Street 1:6600 66TH ST N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-5040
Practice Address - Country:US
Practice Address - Phone:727-343-0600
Practice Address - Fax:727-344-6163
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1228892085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015450300Medicaid