Healthcare Provider Details

I. General information

NPI: 1639128689
Provider Name (Legal Business Name): MICHAEL SCOTT BLOOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 WOODMAN DR STE 105
DAYTON OH
45432-1446
US

IV. Provider business mailing address

1020 WOODMAN DR STE 105
DAYTON OH
45432-1446
US

V. Phone/Fax

Practice location:
  • Phone: 937-723-7772
  • 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 Number35066075B
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: