Provider Demographics
NPI:1336320167
Name:IGOR M BRON M D INC
Entity Type:Organization
Organization Name:IGOR M BRON M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BRON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-929-6260
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92546-0788
Mailing Address - Country:US
Mailing Address - Phone:951-929-6260
Mailing Address - Fax:951-765-2855
Practice Address - Street 1:600 N HIGHLAND SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3046
Practice Address - Country:US
Practice Address - Phone:951-929-6260
Practice Address - Fax:951-765-2855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64227207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA64227OtherLICENSE NUMBER
CA00A642270Medicaid
CAZZZ29192ZMedicare PIN
CA00A642270Medicaid