Provider Demographics
NPI:1720293905
Name:BREDOW, RONALD J (PT)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:J
Last Name:BREDOW
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:RONALD
Other - Middle Name:J
Other - Last Name:BREDOW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:150 GARDINERS AVE
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-3707
Mailing Address - Country:US
Mailing Address - Phone:516-520-7200
Mailing Address - Fax:516-520-7625
Practice Address - Street 1:150 GARDINERS AVE
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-3707
Practice Address - Country:US
Practice Address - Phone:516-520-7200
Practice Address - Fax:516-520-7625
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021022-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY162552POtherHIP
NYQ13C11OtherBCBS RON
NY162552POtherHIP