Provider Demographics
NPI:1962596478
Name:BLOOMBERG, BRAD E (OD)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:E
Last Name:BLOOMBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 PARK HARBOUR DR.
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512
Mailing Address - Country:US
Mailing Address - Phone:330-758-6282
Mailing Address - Fax:
Practice Address - Street 1:1449 BOARDMAN CANFIELD RD STE 230
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-8053
Practice Address - Country:US
Practice Address - Phone:330-758-6671
Practice Address - Fax:330-758-1451
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4008/T-032152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0754045Medicaid
OH0754045Medicaid
OHBLO617811Medicare ID - Type Unspecified