Provider Demographics
NPI:1104210053
Name:BONGIORNO, PETER (ND, LAC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:BONGIORNO
Suffix:
Gender:M
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 BRETON WAY
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2665
Mailing Address - Country:US
Mailing Address - Phone:917-710-6852
Mailing Address - Fax:
Practice Address - Street 1:345 7TH AVE
Practice Address - Street 2:16TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5006
Practice Address - Country:US
Practice Address - Phone:631-421-1848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002612-1171100000X
WANT00001298175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist