Healthcare Provider Details

I. General information

NPI: 1275919797
Provider Name (Legal Business Name): BRONSON BENNO JOSEPH RAJA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S PELHAM PKWY BUILDING 1, 3N, 1C
THE BRONX NY
10461-1046
US

IV. Provider business mailing address

1400 S PELHAM PKWY BUILDING 1, 3N, 1C
THE BRONX NY
10461
US

V. Phone/Fax

Practice location:
  • Phone: 718-918-3203
  • Fax:
Mailing address:
  • Phone: 718-918-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR6803
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number311579
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: