Provider Demographics
NPI:1588772115
Name:BLOOMBERG, JASON MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:MICHAEL
Last Name:BLOOMBERG
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:PO BOX 21004
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-426-4673
Mailing Address - Fax:307-426-4674
Practice Address - Street 1:3100 HENDERSON DR
Practice Address - Street 2:SUITE 9
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5846
Practice Address - Country:US
Practice Address - Phone:307-426-4673
Practice Address - Fax:307-426-4674
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6713A207P00000X, 207Q00000X, 207QB0002X
NE22927207Q00000X, 207P00000X
NV11910207Q00000X, 207VX0000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119416000Medicaid
NV100509999Medicaid
NV1005509998Medicaid
NVWQBHV120739Medicare ID - Type Unspecified
WY119416000Medicaid
WYH76976Medicare UPIN
NEH76976Medicare UPIN
NV100509999Medicaid