Provider Demographics
NPI:1578658720
Name:DICICCO-BLOOM, EMANUEL M (MD)
Entity type:Individual
Prefix:DR
First Name:EMANUEL
Middle Name:M
Last Name:DICICCO-BLOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 WEST GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:89 FRENCH ST STE 2300
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1935
Practice Address - Country:US
Practice Address - Phone:732-235-7875
Practice Address - Fax:732-235-6620
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA547812080P0008X
NJ25MA054781002080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0870706Medicaid
NJ800904C6WMedicare PIN
NJ0870706Medicaid
E62070Medicare UPIN
NJ606916C6WMedicare PIN