Provider Demographics
NPI:1689775173
Name:BLOOM, MELISSA M (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:M
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:M D
Mailing Address - Street 1:1314 S KING ST
Mailing Address - Street 2:SUITE 514
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1956
Mailing Address - Country:US
Mailing Address - Phone:808-591-8611
Mailing Address - Fax:
Practice Address - Street 1:1314 S KING ST
Practice Address - Street 2:SUITE 514
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1956
Practice Address - Country:US
Practice Address - Phone:808-591-8611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD13104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI57549102Medicaid
HI57549102Medicaid
HII35881Medicare UPIN