Provider Demographics
NPI:1073537767
Name:BONASERA, ROBERT J (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:BONASERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1205 FRANKLIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-1600
Mailing Address - Country:US
Mailing Address - Phone:516-222-0067
Mailing Address - Fax:516-222-0071
Practice Address - Street 1:1205 FRANKLIN AVE STE 150
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-222-0067
Practice Address - Fax:516-222-0071
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY237615-1207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY237615OtherLICENSE #
NYFB 0033 059OtherDEA #
NYFB 0033 059OtherDEA #
NYI64585Medicare UPIN