Provider Demographics
NPI:1770666349
Name:BLOOMINGBURG, L. W (OD)
Entity Type:Individual
Prefix:DR
First Name:L.
Middle Name:W
Last Name:BLOOMINGBURG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:138 S. WASHINGTON AVENUE
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-0367
Mailing Address - Country:US
Mailing Address - Phone:731-989-3511
Mailing Address - Fax:731-989-3515
Practice Address - Street 1:138 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:38340-2323
Practice Address - Country:US
Practice Address - Phone:731-989-3511
Practice Address - Fax:731-989-3515
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN359351BMedicaid
TN0123960001Medicare NSC
TN359351BMedicaid
TNT61142Medicare UPIN