Provider Demographics
NPI:1194107227
Name:BLOOM, JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
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 1:230 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-1263
Mailing Address - Country:US
Mailing Address - Phone:937-531-2268
Mailing Address - Fax:937-531-2390
Practice Address - Street 1:230 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-1263
Practice Address - Country:US
Practice Address - Phone:937-531-2268
Practice Address - Fax:937-531-2390
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35. 021640302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization