Provider Demographics
NPI:1881608370
Name:BLOOM, MYRON J (MD)
Entity type:Individual
Prefix:DR
First Name:MYRON
Middle Name:J
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 1:3801 KATELLA AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3381
Mailing Address - Country:US
Mailing Address - Phone:562-596-4645
Mailing Address - Fax:562-596-2225
Practice Address - Street 1:3801 KATELLA AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3381
Practice Address - Country:US
Practice Address - Phone:562-596-4645
Practice Address - Fax:562-596-2225
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG171592086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G171590Medicaid
A40002Medicare UPIN
G17159Medicare ID - Type Unspecified