Provider Demographics
NPI:1336609775
Name:BLOOM, BROOKE ELIZABETH (DO)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELIZABETH
Last Name:BLOOM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SUMMER ST STE 230S
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1216
Mailing Address - Country:US
Mailing Address - Phone:508-368-3150
Mailing Address - Fax:508-368-3152
Practice Address - Street 1:123 SUMMER ST STE 230S
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-368-3150
Practice Address - Fax:508-368-3152
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT737352084N0400X
MA10198792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110153666AMedicaid