Provider Demographics
NPI:1548202526
Name:BLOOM, CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 MONA LISA ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89044-0318
Mailing Address - Country:US
Mailing Address - Phone:702-837-9195
Mailing Address - Fax:
Practice Address - Street 1:1800 W CHARLESTON BLVD
Practice Address - Street 2:UNIVERSITY MEDICAL CENTER
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2329
Practice Address - Country:US
Practice Address - Phone:702-383-1958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI510104304207P00000X
NV1111207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114835231Medicaid
MICB014304OtherBC/BS
MI114835231Medicaid
MIH91166Medicare UPIN