Provider Demographics
NPI:1396719472
Name:BRONSON, MARK RICHARD (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:BRONSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5521 BELLAIRE DR S
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76109-8838
Mailing Address - Country:US
Mailing Address - Phone:817-732-4441
Mailing Address - Fax:
Practice Address - Street 1:5521 BELLAIRE DR S
Practice Address - Street 2:SUITE 100
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109-8838
Practice Address - Country:US
Practice Address - Phone:817-732-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4065111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001251001Medicaid
TX4065OtherSTATE LICENSE
TX751839034OtherTAX ID