Provider Demographics
NPI:1760473193
Name:BLOOM, MONA B (MD)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:B
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MONA
Other - Middle Name:SUSAN
Other - Last Name:BAUCHSBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 4346
Mailing Address - Street 2:DEPT 401
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4346
Mailing Address - Country:US
Mailing Address - Phone:713-331-1850
Mailing Address - Fax:713-521-7710
Practice Address - Street 1:12951 SOUTH FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77047-1923
Practice Address - Country:US
Practice Address - Phone:713-526-5771
Practice Address - Fax:713-526-2036
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH98252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G11104Medicare UPIN
8929B8Medicare ID - Type Unspecified
8D4162Medicare ID - Type Unspecified