Provider Demographics
NPI:1417365313
Name:BRONDON FOOT AND ANKLE LLC
Entity type:Organization
Organization Name:BRONDON FOOT AND ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRONDON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:937-433-0444
Mailing Address - Street 1:77 W ELMWOOD DR STE 311
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4278
Mailing Address - Country:US
Mailing Address - Phone:937-433-0444
Mailing Address - Fax:937-433-0405
Practice Address - Street 1:27 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:OH
Practice Address - Zip Code:45050-1146
Practice Address - Country:US
Practice Address - Phone:937-433-0444
Practice Address - Fax:937-433-0405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-24
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003616213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6891920002Medicare NSC