Provider Demographics
NPI:1467499665
Name:BLOOM, RUSSELL C (DO)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:C
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2452 WEST DRY DRY CREEK CT
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120
Mailing Address - Country:US
Mailing Address - Phone:303-819-4711
Mailing Address - Fax:303-840-8442
Practice Address - Street 1:19641 E PARKER SQUARE DR
Practice Address - Street 2:SUITE A
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-7399
Practice Address - Country:US
Practice Address - Phone:303-840-3800
Practice Address - Fax:303-840-8442
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2014-02-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO32685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO05001552Medicaid
CO05001552Medicaid
COF99751Medicare UPIN