Provider Demographics
NPI:1295199545
Name:BONVILLE, JOSHUA (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:
Last Name:BONVILLE
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 1:725 EAST ADAMS ST
Mailing Address - Street 2:4TH FL
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2576
Mailing Address - Country:US
Mailing Address - Phone:315-464-5831
Mailing Address - Fax:315-464-2030
Practice Address - Street 1:725 EAST ADAMS ST
Practice Address - Street 2:4TH FL
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2576
Practice Address - Country:US
Practice Address - Phone:315-464-5831
Practice Address - Fax:315-464-2030
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297873208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05704141Medicaid