Provider Demographics
NPI:1689623738
Name:BRONGE, MATTHEW R (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:R
Last Name:BRONGE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 JOHN MUIR PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513
Mailing Address - Country:US
Mailing Address - Phone:925-634-6101
Mailing Address - Fax:
Practice Address - Street 1:350 JOHN MUIR PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513
Practice Address - Country:US
Practice Address - Phone:925-634-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9473152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1096480001Medicare NSC
CAU30705Medicare UPIN