Healthcare Provider Details

I. General information

NPI: 1578512893
Provider Name (Legal Business Name): ROBERT TODD BLOOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PLZ
DAYTON OH
45404-1898
US

IV. Provider business mailing address

1 CHILDRENS PLZ
DAYTON OH
45404-1898
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-3020
  • Fax: 937-226-9605
Mailing address:
  • Phone: 937-723-7772
  • Fax: 937-226-9605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number207W00000X
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number35060138
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: