Provider Demographics
NPI:1457386104
Name:BLOOM, ROBERT A (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
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 1:2900 S HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-5612
Mailing Address - Country:US
Mailing Address - Phone:850-481-1687
Mailing Address - Fax:850-640-0761
Practice Address - Street 1:2900 S HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-5612
Practice Address - Country:US
Practice Address - Phone:850-481-1687
Practice Address - Fax:850-640-0761
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5061208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184011802Medicaid
TX184011801Medicaid
TX184011801Medicaid
TX8K9154Medicare PIN
TX184011802Medicaid