Provider Demographics
NPI:1043268998
Name:BONELLI, LANDY E (MD)
Entity Type:Individual
Prefix:DR
First Name:LANDY
Middle Name:E
Last Name:BONELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7071 S 13TH ST
Mailing Address - Street 2:STE 104
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-1466
Mailing Address - Country:US
Mailing Address - Phone:414-570-7106
Mailing Address - Fax:414-570-7136
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-649-7299
Practice Address - Fax:414-649-6694
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19657-020207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30172900Medicaid
WI30172900Medicaid
WIB51651Medicare UPIN