Provider Demographics
NPI:1306941620
Name:BLOOM, ERNEST (MD)
Entity type:Individual
Prefix:
First Name:ERNEST
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 1:501 S SHORE CTR W
Mailing Address - Street 2:103A
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-5762
Mailing Address - Country:US
Mailing Address - Phone:510-227-7028
Mailing Address - Fax:510-274-7119
Practice Address - Street 1:501 S SHORE CTR W
Practice Address - Street 2:103A
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-5762
Practice Address - Country:US
Practice Address - Phone:510-227-7028
Practice Address - Fax:510-274-7119
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56359207N00000X, 207ND0101X, 207ND0900X, 207NI0002X, 207NP0225X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H08795Medicare UPIN
00G563590Medicare ID - Type Unspecified