Healthcare Provider Details

I. General information

NPI: 1699767475
Provider Name (Legal Business Name): BARRY D. BRONSTEIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8305 GRAND RIVER AVE
DETROIT MI
48204-2231
US

IV. Provider business mailing address

27774 FRANKLIN RD
SOUTHFIELD MI
48034-2352
US

V. Phone/Fax

Practice location:
  • Phone: 313-894-1900
  • Fax: 313-894-4206
Mailing address:
  • Phone: 248-356-5555
  • Fax: 248-356-5544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101007671
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: