Provider Demographics
NPI:1376537076
Name:BLOOM, GENEVIEVE E (MD)
Entity Type:Individual
Prefix:DR
First Name:GENEVIEVE
Middle Name:E
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 10TH ST
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3401
Mailing Address - Country:US
Mailing Address - Phone:619-435-0268
Mailing Address - Fax:619-435-1420
Practice Address - Street 1:1117 10TH ST
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3401
Practice Address - Country:US
Practice Address - Phone:619-435-0268
Practice Address - Fax:619-435-1420
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55250207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A552500Medicaid
CA00A552500Medicaid
G62691Medicare UPIN
CAG68691Medicare UPIN