Provider Demographics
NPI:1679799761
Name:BLOOM, STEPHANIE R (M D)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:BLOOM
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UCSF MEDICAL CENTER CHILDRENS HOSPITAL
Mailing Address - Street 2:400 PARNASSUS AVENUE 2ND FLOOR
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0374
Mailing Address - Country:US
Mailing Address - Phone:415-353-2000
Mailing Address - Fax:
Practice Address - Street 1:UCSF MEDICAL CENTER CHILDRENS HOSPITAL
Practice Address - Street 2:400 PARNASSUS AVENUE 2ND FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-0374
Practice Address - Country:US
Practice Address - Phone:415-353-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72493208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G724930OtherMEDI-CAL
CAF53233Medicare UPIN