Provider Demographics
NPI:1205186475
Name:BONAZINCA, JUSTIN
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:BONAZINCA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15635 EXPEDITION ST.
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787
Mailing Address - Country:US
Mailing Address - Phone:772-370-9926
Mailing Address - Fax:
Practice Address - Street 1:5671 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809
Practice Address - Country:US
Practice Address - Phone:407-888-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist