Healthcare Provider Details

I. General information

NPI: 1932284528
Provider Name (Legal Business Name): GARY BRONSTEIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 NW MERCY DR SUITE 300
ROSEBURG OR
97471-2348
US

IV. Provider business mailing address

2801 NW MERCY DR STE 340
ROSEBURG OR
97471-2348
US

V. Phone/Fax

Practice location:
  • Phone: 541-677-1555
  • Fax: 541-677-2113
Mailing address:
  • Phone: 541-677-4319
  • Fax: 541-677-2294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD27814
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: