Healthcare Provider Details

I. General information

NPI: 1225026701
Provider Name (Legal Business Name): BRONSON E TERRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 POMFRET ST
PUTNAM CT
06260-1836
US

IV. Provider business mailing address

320 POMFRET ST
PUTNAM CT
06260-1836
US

V. Phone/Fax

Practice location:
  • Phone: 860-963-6390
  • Fax: 860-963-6343
Mailing address:
  • Phone: 860-963-6390
  • Fax: 860-963-6343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number043624
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: