Healthcare Provider Details

I. General information

NPI: 1568428910
Provider Name (Legal Business Name): MARC BLOOMENSTEIN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 04/26/2022
Certification Date: 04/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8416 E SHEA BLVD # C-101
SCOTTSDALE AZ
85260-6666
US

IV. Provider business mailing address

8416 E SHEA BLVD # C-101
SCOTTSDALE AZ
85260-6666
US

V. Phone/Fax

Practice location:
  • Phone: 480-483-3937
  • Fax:
Mailing address:
  • Phone: 480-483-3937
  • Fax: 480-483-8813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number884
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number884
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: