Healthcare Provider Details

I. General information

NPI: 1669472148
Provider Name (Legal Business Name): JEFFREY HOWARD BLOOM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20311 SW ACACIA ST SUITE 100
NEWPORT BEACH CA
92660-1733
US

IV. Provider business mailing address

7435 PALOMA DR
HUNTINGTON BEACH CA
92648-6833
US

V. Phone/Fax

Practice location:
  • Phone: 949-263-1242
  • Fax: 949-263-1280
Mailing address:
  • Phone: 714-420-6620
  • Fax: 949-263-1280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A6397
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: