Provider Demographics
NPI:1396826814
Name:BRONFMAN, IDA (MD)
Entity Type:Individual
Prefix:DR
First Name:IDA
Middle Name:
Last Name:BRONFMAN
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 1:4004 BOWNE ST
Mailing Address - Street 2:SUITE 1I
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-6143
Mailing Address - Country:US
Mailing Address - Phone:718-539-3359
Mailing Address - Fax:718-358-3837
Practice Address - Street 1:4004 BOWNE ST
Practice Address - Street 2:SUITE 1I
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6143
Practice Address - Country:US
Practice Address - Phone:718-539-3359
Practice Address - Fax:718-358-3837
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199887207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02517393Medicaid
NY01580827Medicaid
06205GMedicare PIN
Y06625Medicare UPIN
NY02517393Medicaid
01921Medicare PIN