Basic Information
| Provider Information | |||||||||
| NPI: | 1750341152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRONDZ | ||||||||
| FirstName: | IGOR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 955534 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631953539 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 1ST CAPITOL DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633012882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366692332 | ||||||||
| FaxNumber: | 6366692401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 103336 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 209782705 | 05 | MO | MEDICAID |