Provider Demographics
NPI:1710993381
Name:BLOOMGARDEN, GARY M (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:BLOOMGARDEN
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 1:5012 S US HWY 75, SUITE 300
Mailing Address - Street 2:ATTN BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4587
Mailing Address - Country:US
Mailing Address - Phone:903-416-6460
Mailing Address - Fax:903-416-6461
Practice Address - Street 1:5012 S US HIGHWAY 75 STE 240
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4588
Practice Address - Country:US
Practice Address - Phone:903-416-6460
Practice Address - Fax:903-416-6461
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023954207T00000X
TXQ0224207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTE27940Medicare UPIN
CT140000109Medicare ID - Type Unspecified
TX358411YKQLMedicare PIN