Provider Demographics
NPI:1790881639
Name:BLOOM, BRETT W
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:W
Last Name:BLOOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 CORTE JARDIN
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-9253
Mailing Address - Country:US
Mailing Address - Phone:760-918-9200
Mailing Address - Fax:760-918-9203
Practice Address - Street 1:2077 LAS PALMAS DR
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1519
Practice Address - Country:US
Practice Address - Phone:760-918-9200
Practice Address - Fax:760-918-9203
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26571225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT26571BMedicare UPIN