Provider Demographics
NPI:1275576290
Name:BONANNO, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:BONANNO
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 1:1007 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:BELMAR
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-2328
Mailing Address - Country:US
Mailing Address - Phone:732-556-6957
Mailing Address - Fax:
Practice Address - Street 1:651 WILOW GROVE AVENUE
Practice Address - Street 2:HACKETTSTOWN REGIONAL MED. CTR. -EMERGENCY DEPT
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07849
Practice Address - Country:US
Practice Address - Phone:908-856-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04728000207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F13774Medicare UPIN
NJ039565Medicare ID - Type Unspecified