Provider Demographics
NPI:1750457404
Name:BRONSTEIN, MARK A (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:BRONSTEIN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11180 WARNER AVE STE 163
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7515
Mailing Address - Country:US
Mailing Address - Phone:714-751-1188
Mailing Address - Fax:714-751-2403
Practice Address - Street 1:11180 WARNER AVE #163
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:714-751-1188
Practice Address - Fax:714-751-2403
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2012-02-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG44667207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0162028Medicaid
A92508Medicare UPIN
G44667Medicare ID - Type Unspecified