Healthcare Provider Details

I. General information

NPI: 1770322299
Provider Name (Legal Business Name): BLOOM PHYSICIAN HOUSECALLS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 W IH 10 STE 240
SAN ANTONIO TX
78230-3868
US

IV. Provider business mailing address

12600 W COLFAX AVE STE B200
LAKEWOOD CO
80215-3736
US

V. Phone/Fax

Practice location:
  • Phone: 303-993-1330
  • Fax:
Mailing address:
  • Phone: 720-923-1250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBRA MOON WADELTON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 720-923-1250