Provider Demographics
NPI:1285773457
Name:BLOOM, CHARLES STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:STEPHEN
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 1:1371 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5512
Mailing Address - Country:US
Mailing Address - Phone:321-794-4747
Mailing Address - Fax:321-794-4747
Practice Address - Street 1:1371 HARMON AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-5512
Practice Address - Country:US
Practice Address - Phone:321-794-4747
Practice Address - Fax:407-740-5251
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL40849207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008921300Medicaid
FL008921300Medicaid