Provider Demographics
NPI:1669472148
Name:BLOOM, JEFFREY HOWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:HOWARD
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:7435 PALOMA DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-6833
Mailing Address - Country:US
Mailing Address - Phone:714-420-6620
Mailing Address - Fax:949-263-1280
Practice Address - Street 1:20311 SW ACACIA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1733
Practice Address - Country:US
Practice Address - Phone:949-263-1242
Practice Address - Fax:949-263-1280
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A6397207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A6397OtherSTATE LICENSE NUMBER
CAG01162Medicare UPIN