Provider Demographics
NPI:1376548750
Name:BONZANI, ROBERT A (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:BONZANI
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 1:1615 WINSTED DR
Mailing Address - Street 2:STE 4
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-4696
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 WINSTED DR
Practice Address - Street 2:STE 4
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4696
Practice Address - Country:US
Practice Address - Phone:574-364-2875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03609775174400000X
ND12014208800000X
IN01078104A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5642652OtherAETNA PROVIDER NUMBER
IL036097795Medicaid
ND16290Medicaid
IL964290012OtherPRNGRSMTH MEDICARE PTAN
IL964290012OtherPRNGRSMTH MEDICARE PTAN
ILG81407Medicare UPIN
IL036097795Medicaid
IL5642652OtherAETNA PROVIDER NUMBER