Provider Demographics
NPI:1497018238
Name:KEEBLER BLOOM, CHANDRA NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANDRA
Middle Name:NICOLE
Last Name:KEEBLER BLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CHANDRA
Other - Middle Name:NICOLE
Other - Last Name:KEEBLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:975 SERENO DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2441
Mailing Address - Country:US
Mailing Address - Phone:707-438-5077
Mailing Address - Fax:
Practice Address - Street 1:975 SERENO DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2441
Practice Address - Country:US
Practice Address - Phone:707-438-5077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA131366207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine