Provider Demographics
NPI:1225035835
Name:BLOOM, WAYNE BRIAN (DPM)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:BRIAN
Last Name:BLOOM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 SAW MILL RIVER RD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-4108
Mailing Address - Country:US
Mailing Address - Phone:914-245-7888
Mailing Address - Fax:914-245-7909
Practice Address - Street 1:2050 SAW MILL RIVER RD
Practice Address - Street 2:
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598-4108
Practice Address - Country:US
Practice Address - Phone:914-245-7888
Practice Address - Fax:914-245-7909
Is Sole Proprietor?:No
Enumeration Date:2005-06-29
Last Update Date:2014-02-07
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
NYN-004707213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY480015388OtherMEDICARE RAILROAD
NY480013301OtherMEDICARE RAILROAD
NY480013301OtherMEDICARE RAILROAD
NYU10277Medicare UPIN
NY5625580002Medicare NSC