Healthcare Provider Details

I. General information

NPI: 1477536068
Provider Name (Legal Business Name): KENNETH EDWARD BLOOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 WEST AVE
BRONX NY
10462-7304
US

IV. Provider business mailing address

200 CENTRAL PARK S APT 107
NEW YORK NY
10019-1449
US

V. Phone/Fax

Practice location:
  • Phone: 718-239-1500
  • Fax: 212-765-3210
Mailing address:
  • Phone: 212-262-2500
  • Fax: 212-765-3210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number169466
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: