Healthcare Provider Details

I. General information

NPI: 1477631844
Provider Name (Legal Business Name): MATTHEW BRANDON BLOOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 SAMARITAN DR #504
SAN JOSE CA
95124-4006
US

IV. Provider business mailing address

2505 SAMARITAN DR #504
SAN JOSE CA
95124-4006
US

V. Phone/Fax

Practice location:
  • Phone: 408-356-3753
  • Fax:
Mailing address:
  • Phone: 408-356-3753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA77610
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberA77610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: