Healthcare Provider Details

I. General information

NPI: 1255599742
Provider Name (Legal Business Name): BRONSON ELIZABETH DELASOBERA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6858 OLD DOMINION DR
MC LEAN VA
22101-3899
US

IV. Provider business mailing address

6858 OLD DOMINION DR
MC LEAN VA
22101-3899
US

V. Phone/Fax

Practice location:
  • Phone: 703-288-2790
  • Fax: 703-997-7272
Mailing address:
  • Phone: 703-288-2790
  • Fax: 703-997-7272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD039254
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberFD2576366
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: