Provider Demographics
NPI:1821012261
Name:BROSNAN, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BROSNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2732
Mailing Address - Country:US
Mailing Address - Phone:607-798-9356
Mailing Address - Fax:607-797-1707
Practice Address - Street 1:240 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2732
Practice Address - Country:US
Practice Address - Phone:607-798-9356
Practice Address - Fax:607-797-1707
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170214207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01552170Medicaid
NY01552170Medicaid
NYG01508Medicare UPIN
NY0428860001Medicare NSC