Healthcare Provider Details

I. General information

NPI: 1215249529
Provider Name (Legal Business Name): MICHAEL BRONDON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 W ELMWOOD DR STE 311
DAYTON OH
45459-4278
US

IV. Provider business mailing address

77 W ELMWOOD DR STE 311
DAYTON OH
45459-4278
US

V. Phone/Fax

Practice location:
  • Phone: 937-433-0444
  • Fax: 937-433-0405
Mailing address:
  • Phone: 937-433-0444
  • Fax: 937-433-0405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number36003616
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: