Provider Demographics
NPI:1578567822
Name:BLOOM, GITTE S (MD)
Entity Type:Individual
Prefix:DR
First Name:GITTE
Middle Name:S
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 FLOWER ST
Mailing Address - Street 2:STE A
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-3000
Mailing Address - Country:US
Mailing Address - Phone:818-557-2671
Mailing Address - Fax:818-557-0761
Practice Address - Street 1:607 S GLENOAKS BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1424
Practice Address - Country:US
Practice Address - Phone:818-557-2671
Practice Address - Fax:818-557-0761
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72269208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A722690Medicaid
CAWA72269AMedicare PIN
CA00A722690Medicaid