Provider Demographics
NPI:1205884574
Name:BRONSTEIN, JAGODA EWA (MD)
Entity type:Individual
Prefix:
First Name:JAGODA
Middle Name:EWA
Last Name:BRONSTEIN
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 1:57 WILLOWBROOK BLVD
Mailing Address - Street 2:SUITE 421
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-7045
Mailing Address - Country:US
Mailing Address - Phone:973-754-4025
Mailing Address - Fax:973-754-4044
Practice Address - Street 1:57 WILLOWBROOK BLVD
Practice Address - Street 2:SUITE 421
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7045
Practice Address - Country:US
Practice Address - Phone:973-754-4025
Practice Address - Fax:973-754-4044
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA068548002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G61802Medicare UPIN