Provider Demographics
NPI:1831177948
Name:BLOOM, KEITH D (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:D
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5001 S COOPER ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5993
Mailing Address - Country:US
Mailing Address - Phone:866-367-8768
Mailing Address - Fax:817-541-9555
Practice Address - Street 1:7701 LAS COLINAS RDG STE 460
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-8081
Practice Address - Country:US
Practice Address - Phone:866-367-8768
Practice Address - Fax:817-541-9301
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXP1967208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX295147705Medicaid
TXP01258252OtherMEDICARE RAILROAD
TX295147705Medicaid
TXTXB149352Medicare PIN
TXTXB149351Medicare PIN
TX295147704Medicaid