Provider Demographics
NPI:1003189010
Name:BLOOM, RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:BLOOM
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 1:4105 COSTADO RD.
Mailing Address - Street 2:
Mailing Address - City:PEBBLE BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93953-3004
Mailing Address - Country:US
Mailing Address - Phone:831-626-3256
Mailing Address - Fax:831-626-3268
Practice Address - Street 1:4105 COSTADO RD.
Practice Address - Street 2:
Practice Address - City:PEBBLE BEACH
Practice Address - State:CA
Practice Address - Zip Code:93953-3004
Practice Address - Country:US
Practice Address - Phone:831-626-3256
Practice Address - Fax:831-626-3268
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC27398207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC27398OtherNARCOTICS LICENSE # AB2042012