Provider Demographics
NPI:1053508747
Name:BRONSON, JIM (LMT)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:BRONSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 W DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-2144
Mailing Address - Country:US
Mailing Address - Phone:352-255-9546
Mailing Address - Fax:352-787-3041
Practice Address - Street 1:32815 RADIO RD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-3902
Practice Address - Country:US
Practice Address - Phone:352-787-8531
Practice Address - Fax:352-787-3041
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA24597174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist