Provider Demographics
NPI:1669855953
Name:BLOOM, ASHLIE GAIL (DO)
Entity Type:Individual
Prefix:
First Name:ASHLIE
Middle Name:GAIL
Last Name:BLOOM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JARRETT WHITE RD
Mailing Address - Street 2:
Mailing Address - City:TRIPLER ARMY MEDICAL CENTER
Mailing Address - State:HI
Mailing Address - Zip Code:96859-5001
Mailing Address - Country:US
Mailing Address - Phone:808-433-5334
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:
Practice Address - City:TRIPLER ARMY MEDICAL CENTER
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-5334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-03
Last Update Date:2022-06-13
Deactivation Date:2016-04-04
Deactivation Code:
Reactivation Date:2020-04-15
Provider Licenses
StateLicense IDTaxonomies
390200000X
HIDOS-2265-0208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program