Provider Demographics
NPI:1295855898
Name:ANDERS, BRONWEN JENNEY (MD)
Entity Type:Individual
Prefix:
First Name:BRONWEN
Middle Name:JENNEY
Last Name:ANDERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12106 WILDCAT CANYON RD
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-1521
Mailing Address - Country:US
Mailing Address - Phone:619-445-0707
Mailing Address - Fax:619-445-0988
Practice Address - Street 1:5442 SYCUAN RD
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-1816
Practice Address - Country:US
Practice Address - Phone:619-445-0707
Practice Address - Fax:619-445-0988
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49297174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE02685Medicare UPIN