Provider Demographics
NPI:1053400093
Name:COREY-BLOOM, JODY (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JODY
Middle Name:
Last Name:COREY-BLOOM
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8950 VILLA LA JOLLA DR
Mailing Address - Street 2:C129
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1714
Mailing Address - Country:US
Mailing Address - Phone:858-246-1288
Mailing Address - Fax:858-246-1283
Practice Address - Street 1:8950 VILLA LA JOLLA DR
Practice Address - Street 2:C129
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1714
Practice Address - Country:US
Practice Address - Phone:858-246-1288
Practice Address - Fax:858-246-1283
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0628472084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G628470C06OtherCALOPTIMA PROVIDER NUMBER
4845OtherCMS
130007027OtherRAILROAD MEDICARE
CA00G628470Medicaid
4845OtherCMS