Provider Demographics
NPI:1790740314
Name:BRONER, THOMAS P (DPM)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:BRONER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 PINE NOTCH PL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-4411
Mailing Address - Country:US
Mailing Address - Phone:904-251-5053
Mailing Address - Fax:904-895-6056
Practice Address - Street 1:5301 PINE NOTCH PL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-4411
Practice Address - Country:US
Practice Address - Phone:904-472-6536
Practice Address - Fax:904-895-6056
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO924213E00000X
FLPO0924213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041050100Medicaid
T84644Medicare UPIN
FL041050100Medicaid
21698LMedicare PIN