Provider Demographics
NPI:1013158427
Name:BLOOMGARDEN, JESSICA (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:BLOOMGARDEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 MONTCLAIRE DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3587
Mailing Address - Country:US
Mailing Address - Phone:646-265-9264
Mailing Address - Fax:
Practice Address - Street 1:4399 N NOB HILL RD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-5813
Practice Address - Country:US
Practice Address - Phone:954-746-1505
Practice Address - Fax:954-746-1562
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-13
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251635208100000X
NJ25MA08531600208100000X
FLME116270208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1013158427Medicare PIN