Provider Demographics
NPI:1407919558
Name:BLOOM, BARBARA (OD)
Entity Type:Individual
Prefix:
First Name:BARBARA
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 1:4392 STURBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-3674
Mailing Address - Country:US
Mailing Address - Phone:717-652-7710
Mailing Address - Fax:717-541-9842
Practice Address - Street 1:4392 STURBRIDGE DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-3674
Practice Address - Country:US
Practice Address - Phone:717-652-7710
Practice Address - Fax:717-541-9842
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000267152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU11153Medicare UPIN
PA650707X3XMedicare PIN