Provider Demographics
NPI:1013977206
Name:BLOOMFIELD, ELLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIE
Middle Name:
Last Name:BLOOMFIELD
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 1:1808 VERDUGO BLVD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1477
Mailing Address - Country:US
Mailing Address - Phone:818-790-7098
Mailing Address - Fax:818-790-7099
Practice Address - Street 1:1808 VERDUGO BLVD
Practice Address - Street 2:SUITE 403
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1477
Practice Address - Country:US
Practice Address - Phone:818-790-7098
Practice Address - Fax:818-790-7099
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65919207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG65919Medicare ID - Type Unspecified
CAF01151Medicare UPIN