Provider Demographics
NPI:1952310773
Name:LARRY M. BLOOM OD
Entity Type:Organization
Organization Name:LARRY M. BLOOM OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-882-8467
Mailing Address - Street 1:5600 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2731
Mailing Address - Country:US
Mailing Address - Phone:419-882-8467
Mailing Address - Fax:419-882-8951
Practice Address - Street 1:5600 MONROE ST STE 102
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2731
Practice Address - Country:US
Practice Address - Phone:419-882-8467
Practice Address - Fax:419-882-8951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2757/T1242152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0465262Medicare PIN