Healthcare Provider Details

I. General information

NPI: 1982751558
Provider Name (Legal Business Name): MICHAEL M. BRONSHVAG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 COMMERCIAL BLVD SUITE 108
NOVATO CA
94949-6175
US

IV. Provider business mailing address

10 COMMERCIAL BLVD SUITE 108
NOVATO CA
94949-6175
US

V. Phone/Fax

Practice location:
  • Phone: 415-506-0262
  • Fax: 415-506-0275
Mailing address:
  • Phone: 415-506-0262
  • Fax: 415-506-0275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: