Provider Demographics
NPI:1568586600
Name:BLOOM, BERNARD (OD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:
Last Name:BLOOM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1007
Mailing Address - Country:US
Mailing Address - Phone:269-945-2192
Mailing Address - Fax:269-945-3937
Practice Address - Street 1:1510 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1007
Practice Address - Country:US
Practice Address - Phone:269-945-2192
Practice Address - Fax:269-945-3937
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002224152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2813629Medicaid
MIT33907Medicare UPIN
MIN87460002Medicare ID - Type Unspecified
MI2813629Medicaid