Provider Demographics
NPI:1003080045
Name:ROBERT B. BRONFMAN
Entity Type:Organization
Organization Name:ROBERT B. BRONFMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRONFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:703-437-5353
Mailing Address - Street 1:112 ELDEN STREET
Mailing Address - Street 2:STE D
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-4832
Mailing Address - Country:US
Mailing Address - Phone:703-437-5353
Mailing Address - Fax:703-437-6941
Practice Address - Street 1:112 ELDEN STREET
Practice Address - Street 2:SUITE D
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4832
Practice Address - Country:US
Practice Address - Phone:703-437-5353
Practice Address - Fax:703-437-6941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000645213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3865210001Medicare NSC
VAU69245Medicare PIN
VA043176Medicare PIN