Provider Demographics
NPI:1578643060
Name:BLOOM, STUART M (MD)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:M
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2533 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2618
Mailing Address - Country:US
Mailing Address - Phone:805-652-2244
Mailing Address - Fax:805-652-0469
Practice Address - Street 1:2533 E MAIN ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2618
Practice Address - Country:US
Practice Address - Phone:805-652-2244
Practice Address - Fax:805-652-0469
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27742207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG27742OtherSTATE LICENSE
CAA43475Medicare UPIN
CAG27742Medicare PIN