Healthcare Provider Details

I. General information

NPI: 1801886163
Provider Name (Legal Business Name): BRENDA KRONBORG D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 06/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8405 E BASELINE RD SUITE 107
MESA AZ
85209-4349
US

IV. Provider business mailing address

PO BOX 16455
MESA AZ
85211-6455
US

V. Phone/Fax

Practice location:
  • Phone: 480-615-2010
  • Fax: 480-218-6053
Mailing address:
  • Phone: 480-615-2010
  • Fax: 480-962-0523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number3092
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: