Provider Demographics
NPI:1154367324
Name:BRONSON, DAVIS L (MD)
Entity type:Individual
Prefix:
First Name:DAVIS
Middle Name:L
Last Name:BRONSON
Suffix:
Gender:
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:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0719
Mailing Address - Country:US
Mailing Address - Phone:509-837-1617
Mailing Address - Fax:
Practice Address - Street 1:355 CHARDONNAY AVE
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-9521
Practice Address - Country:US
Practice Address - Phone:509-781-6366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002029450208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205970908Medicaid
KS100430470AMedicaid
MO166067OtherANTHEM
OK200000520AMedicaid
240007925OtherRR MEDICARE
OK200000520AMedicaid
MO001013786Medicare PIN