Provider Demographics
NPI:1033104880
Name:BONIFACIO, DANIEL L (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:BONIFACIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2891 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5328
Mailing Address - Country:US
Mailing Address - Phone:231-935-6080
Mailing Address - Fax:231-935-6081
Practice Address - Street 1:1200 SIXTH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2369
Practice Address - Country:US
Practice Address - Phone:231-935-5800
Practice Address - Fax:231-935-5799
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011505207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4204742Medicaid
MIG95950Medicare UPIN
MI0B84507012Medicare ID - Type Unspecified
MIMI3686002Medicare PIN