Healthcare Provider Details

I. General information

NPI: 1992807150
Provider Name (Legal Business Name): CLARENCE JAMES BRONSTEMA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 S HICKORY STREET
MELBOURNE FL
32901
US

IV. Provider business mailing address

PO BOX 361907
MELBOURNE FL
32906-1907
US

V. Phone/Fax

Practice location:
  • Phone: 321-254-6218
  • Fax: 321-254-6230
Mailing address:
  • Phone: 321-254-6218
  • Fax: 321-254-6230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS9722
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: