Provider Demographics
NPI:1982658225
Name:BLOOMSTON, PAUL MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MARK
Last Name:BLOOMSTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2160 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1410
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:4571 COLONIAL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1156
Practice Address - Country:US
Practice Address - Phone:239-333-0995
Practice Address - Fax:844-615-5267
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2017-04-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH350842712086X0206X
FLME1250242086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL385460OtherAVMED
FLP01547650OtherRR MEDICARE
FL1191282OtherWELLCARE
FLQMP000005121963OtherMOLINA
FL015646100Medicaid
FL7073160OtherCIGNA
FL7438862OtherAETNA
FLP1032667OtherFREEDOM
FL151EVOtherBCBS
OH2659814Medicaid
FLP971025OtherOPTIMUM
FLP1032667OtherFREEDOM
FL151EVOtherBCBS