=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497809990
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN K. BRONZO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 03/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 VAN NESS AVE FL 3
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94109-6919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-600-3232
-----------------------------------------------------
Fax | 415-447-6335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 6102
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94948-6102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-884-3404
-----------------------------------------------------
Fax | 415-883-0877
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | C55257
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | 238570
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | C55257
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------