Provider Demographics
NPI:1407891609
Name:BONVICINO, MARIE L (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:L
Last Name:BONVICINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-3348
Mailing Address - Country:US
Mailing Address - Phone:732-914-1919
Mailing Address - Fax:732-341-3303
Practice Address - Street 1:222 OAK AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-3348
Practice Address - Country:US
Practice Address - Phone:732-914-1919
Practice Address - Fax:732-341-3303
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06624300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0062754000OtherAMERIHEALTH NJ PA DEL
NJ3023421OtherCIGNA COMED
NJ7653506Medicaid
NJG02909OtherHEALTH NET PHS
NJP732138OtherOXFORD
NJ010066243NJ01OtherST BARNABAS HEALTH
NJ341407OtherAMERIHEALTH ADMIN
NJ3023421001OtherCIGNA HMO
NJ341407OtherAMERIHEALTH ADMIN
NJ3023421001OtherCIGNA HMO