Provider Demographics
NPI:1205866688
Name:BRONSON, WENDELL D (DO)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:D
Last Name:BRONSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 N RIVERSIDE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64507-2553
Mailing Address - Country:US
Mailing Address - Phone:816-271-7979
Mailing Address - Fax:816-271-7971
Practice Address - Street 1:802 N RIVERSIDE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64507-2553
Practice Address - Country:US
Practice Address - Phone:816-271-7979
Practice Address - Fax:816-271-7971
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4J27207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO19482014OtherBLUE SHIELD KC
MO10001146000OtherCHP
MO243710209Medicaid
MO4570541OtherAETNA
KS100232910BMedicaid
MO660001114Medicare ID - Type UnspecifiedRAILROAD
MO243710209Medicaid
MOE39885Medicare UPIN
KS100232910BMedicaid