Provider Demographics
NPI:1245602853
Name:BONGATO, DEXTER
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:
Last Name:BONGATO
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 1:6805 FRESH POND RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5200
Mailing Address - Country:US
Mailing Address - Phone:718-456-2545
Mailing Address - Fax:718-559-6784
Practice Address - Street 1:6805 FRESH POND RD
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5200
Practice Address - Country:US
Practice Address - Phone:718-456-2545
Practice Address - Fax:718-559-6784
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036357261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy