Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | X003040-1 | NY |
NPI | 1619174174 |
---|---|
Provider Name | Dr. Bruce David Bloom |
First Address | White Plains, NY 10603-4032 |
Second Address | White Plains, NY 10603-4032 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2007 |
Last Update Date | 08/07/2007 |