Provider Demographics
NPI:1285639294
Name:VADER, BONNIE (DPM)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:
Last Name:VADER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 ELDORADO BLVD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-4624
Mailing Address - Country:US
Mailing Address - Phone:516-297-6522
Mailing Address - Fax:516-827-1971
Practice Address - Street 1:621 AMBOY ST
Practice Address - Street 2:APT 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-4724
Practice Address - Country:US
Practice Address - Phone:718-345-2935
Practice Address - Fax:718-345-2940
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004730213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01247630Medicaid
NY36966POtherHIP
NYN004730-A41OtherHEALTH FIRST
NY6200135OtherGHI
NYKS581OtherOXFORD HEALTH PLAN
NYA400000846Medicare PIN
NYP53361Medicare PIN
NY36966POtherHIP