Provider Demographics
NPI:1740245299
Name:BRONNER, MARY P (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:P
Last Name:BRONNER
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 1:500 CHIPETA
Mailing Address - Street 2:ARUP LABORATORIES
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108
Mailing Address - Country:US
Mailing Address - Phone:801-583-2787
Mailing Address - Fax:801-581-0735
Practice Address - Street 1:500 CHIPETA
Practice Address - Street 2:ARUP LABORATORIES
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108
Practice Address - Country:US
Practice Address - Phone:801-583-2787
Practice Address - Fax:801-581-0735
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083002B207ZP0101X
UT7817974-1205207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2449872Medicaid
P00907176OtherRAILROAD MEDICARE
OHBR4124971Medicare PIN
P00907176OtherRAILROAD MEDICARE
OH2449872Medicaid