Provider Demographics
NPI:1265562524
Name:BLOOM, MARK WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILLIAM
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 1:4550 NW 102ND PL
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2276
Mailing Address - Country:US
Mailing Address - Phone:305-599-3788
Mailing Address - Fax:
Practice Address - Street 1:4550 NW 102ND PL
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2276
Practice Address - Country:US
Practice Address - Phone:305-599-3788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL56011208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice