Provider Demographics
NPI:1568505485
Name:BRONNER, BARRY DOUGLAS (OTR)
Entity Type:Individual
Prefix:MR
First Name:BARRY
Middle Name:DOUGLAS
Last Name:BRONNER
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 N 26TH ST
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-1946
Mailing Address - Country:US
Mailing Address - Phone:254-644-9244
Mailing Address - Fax:
Practice Address - Street 1:4800 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-1329
Practice Address - Country:US
Practice Address - Phone:254-297-3770
Practice Address - Fax:254-297-3875
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX106497174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist