Provider Demographics
NPI:1225028244
Name:BRONWEIN, ELLIOT MARK (OD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:MARK
Last Name:BRONWEIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5691
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:17909 SOLEDAD CANYON RD
Practice Address - Street 2:
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91387-3210
Practice Address - Country:US
Practice Address - Phone:661-250-5220
Practice Address - Fax:661-250-5243
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8201TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP8201CMedicare PIN
CAU73114Medicare UPIN