Provider Demographics
NPI:1114984424
Name:BRONSTEIN, SEYMOUR MAYNARD (MD)
Entity Type:Individual
Prefix:
First Name:SEYMOUR
Middle Name:MAYNARD
Last Name:BRONSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1387
Mailing Address - Country:US
Mailing Address - Phone:541-963-2828
Mailing Address - Fax:541-975-5132
Practice Address - Street 1:900 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1387
Practice Address - Country:US
Practice Address - Phone:541-963-2828
Practice Address - Fax:541-975-5132
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27924207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12758Medicaid
NDG48099Medicare UPIN
ND23554Medicare ID - Type Unspecified