Provider Demographics
NPI:1811983372
Name:BLOOM, KENNETH EVAN (DPM)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EVAN
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:137 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6540
Mailing Address - Country:US
Mailing Address - Phone:704-662-8336
Mailing Address - Fax:704-662-8525
Practice Address - Street 1:137 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE C
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6540
Practice Address - Country:US
Practice Address - Phone:704-662-8336
Practice Address - Fax:704-662-8525
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC414213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790800HMedicaid
NC2433273AMedicare PIN
NC5819850001Medicare NSC
NC790800HMedicaid