Provider Demographics
NPI:1689667446
Name:BLOOMFIELD, DENNIS A (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:A
Last Name:BLOOMFIELD
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 1:1102 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3622
Mailing Address - Country:US
Mailing Address - Phone:718-442-5230
Mailing Address - Fax:718-816-4927
Practice Address - Street 1:1102 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3622
Practice Address - Country:US
Practice Address - Phone:718-442-5230
Practice Address - Fax:718-816-4927
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099669174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYOS240OtherOXFORD
0057365OtherGHI
NY498281Medicare ID - Type Unspecified
NYC10539Medicare UPIN