Provider Demographics
NPI:1255333027
Name:BRONOV, OLEG E (MD)
Entity Type:Individual
Prefix:DR
First Name:OLEG
Middle Name:E
Last Name:BRONOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:OLEG
Other - Middle Name:ERLENOVICH
Other - Last Name:BRONOV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-7802
Practice Address - Country:US
Practice Address - Phone:570-271-6301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4205862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001957221Medicaid
PA001957221Medicaid
PA069506Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER