Provider Demographics
NPI:1407377591
Name:BRONSON, JONATHAN SAMUEL (L AC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SAMUEL
Last Name:BRONSON
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 AMERICANA DR APT 51
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-3192
Mailing Address - Country:US
Mailing Address - Phone:410-212-4181
Mailing Address - Fax:
Practice Address - Street 1:645 RIDGELY AVE
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1069
Practice Address - Country:US
Practice Address - Phone:410-266-9370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02135171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist