Provider Demographics
NPI:1417005737
Name:BLOOM, DAVID R (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:17822 BEACH BLVD
Mailing Address - Street 2:#325
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-7101
Mailing Address - Country:US
Mailing Address - Phone:714-843-6550
Mailing Address - Fax:714-843-6560
Practice Address - Street 1:17822 BEACH BLVD
Practice Address - Street 2:#325
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647
Practice Address - Country:US
Practice Address - Phone:714-843-6550
Practice Address - Fax:714-843-6560
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2018-07-17
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Provider Licenses
StateLicense IDTaxonomies
CAG069614207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E94626Medicare UPIN