Provider Demographics
NPI:1780766436
Name:BLOOM, LAWRENCE (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 JAMESTOWN ST
Mailing Address - Street 2:STE. 207
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1751
Mailing Address - Country:US
Mailing Address - Phone:215-483-8444
Mailing Address - Fax:215-482-8456
Practice Address - Street 1:525 JAMESTOWN ST
Practice Address - Street 2:STE. 207
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1751
Practice Address - Country:US
Practice Address - Phone:215-483-8444
Practice Address - Fax:215-482-8456
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020108-E207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA182417G5ZMedicare ID - Type Unspecified
PAC32965Medicare UPIN