Healthcare Provider Details

I. General information

NPI: 1649355090
Provider Name (Legal Business Name): DIANE E BLOOMFIELD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MMC - FAMILY CARE CENTER 3444 KOSSUTH AVE. 1ST FL. RM B
BRONX NY
10467
US

IV. Provider business mailing address

890 W END AVE APT. 15C
NEW YORK NY
10025-3526
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-5873
  • Fax:
Mailing address:
  • Phone: 718-920-5873
  • Fax: 718-652-4417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number155749
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: