Provider Demographics
NPI:1912084427
Name:BLOOM, ERIC J (OD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:BLOOM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1020
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-1020
Mailing Address - Country:US
Mailing Address - Phone:845-794-4930
Mailing Address - Fax:845-794-4842
Practice Address - Street 1:38 NORTH ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-1711
Practice Address - Country:US
Practice Address - Phone:845-794-4930
Practice Address - Fax:845-794-4842
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY2879152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00520241Medicaid
NYC27591Medicare PIN
NYT48946Medicare UPIN
NY00520241Medicaid