Provider Demographics
NPI:1194286773
Name:BLOOM, JEFFREY (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 WOODMAN DR STE 105
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432-1410
Mailing Address - Country:US
Mailing Address - Phone:937-723-3248
Mailing Address - Fax:
Practice Address - Street 1:6683 CENTERVILLE BUSINESS PKWY
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-2655
Practice Address - Country:US
Practice Address - Phone:937-723-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2025-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A21241207W00000X
390200000X
OH34.017533207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program