=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962596478
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRAD E. BLOOMBERG O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 09/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1449 BOARDMAN CANFIELD RD STE 230
-----------------------------------------------------
City | BOARDMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-8053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-758-6671
-----------------------------------------------------
Fax | 330-758-1451
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 810 PARK HARBOUR DR.
-----------------------------------------------------
City | YOUNGSTOWN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-758-6282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4008/T-032
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------