Provider Demographics
NPI:1154346377
Name:BLOOM, JEFFREY M (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
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 1:1318 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3314
Mailing Address - Country:US
Mailing Address - Phone:805-541-2300
Mailing Address - Fax:805-541-2301
Practice Address - Street 1:1318 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3314
Practice Address - Country:US
Practice Address - Phone:805-541-2300
Practice Address - Fax:805-541-2301
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72622207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G726221Medicaid
WG72622PMedicare PIN
110167869Medicare PIN
F35013Medicare UPIN