Healthcare Provider Details

I. General information

NPI: 1225035835
Provider Name (Legal Business Name): WAYNE BRIAN BLOOM D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/24/2006

III. Provider practice location address

2050 SAW MILL RIVER RD
YORKTOWN HEIGHTS NY
10598-4108
US

IV. Provider business mailing address

2050 SAW MILL RIVER RD
YORKTOWN HEIGHTS NY
10598-4108
US

V. Phone/Fax

Practice location:
  • Phone: 914-245-7888
  • Fax: 914-245-7909
Mailing address:
  • Phone: 914-245-7888
  • Fax: 914-245-7909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN-004707
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN-004707
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: