Provider Demographics
NPI:1639128689
Name:BLOOM, MICHAEL SCOTT (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SCOTT
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 1:1020 WOODMAN DR STE 105
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432-1446
Mailing Address - Country:US
Mailing Address - Phone:937-723-7772
Mailing Address - Fax:937-226-9605
Practice Address - Street 1:1020 WOODMAN DR STE 105
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-1446
Practice Address - Country:US
Practice Address - Phone:937-723-7772
Practice Address - Fax:937-226-9605
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207W00000X207W00000X
OH35066075B207WX0110X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9111115Medicaid
OH2099223Medicaid
INP00849129Medicare PIN
OH9111115Medicaid
OHG93609Medicare UPIN
263670CMedicare PIN
OHBLO876761Medicare PIN