Provider Demographics
NPI:1710094503
Name:BLOOM, MICHAEL M (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:BLOOM
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:2625 PIEDMONT RD NE
Mailing Address - Street 2:SUITE 36G
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-3086
Mailing Address - Country:US
Mailing Address - Phone:404-233-3513
Mailing Address - Fax:404-814-0184
Practice Address - Street 1:2625 PIEDMONT RD NE
Practice Address - Street 2:SUITE 36G
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3086
Practice Address - Country:US
Practice Address - Phone:404-233-3513
Practice Address - Fax:404-814-0184
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2018-03-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA1262152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCBVGMedicare PIN
GAU30817Medicare UPIN
GA0174090001Medicare NSC