Provider Demographics
NPI:1417234782
Name:BLOOM, DAVID
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:BLOOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 WARBLER PL
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-1267
Mailing Address - Country:US
Mailing Address - Phone:847-903-7623
Mailing Address - Fax:
Practice Address - Street 1:3020 WARBLER PL
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-1267
Practice Address - Country:US
Practice Address - Phone:847-903-7623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1508940183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist