Provider Demographics
NPI:1427008556
Name:BONHOMME, IDLER (LMT MPT)
Entity Type:Individual
Prefix:
First Name:IDLER
Middle Name:
Last Name:BONHOMME
Suffix:
Gender:M
Credentials:LMT MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 680735
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32868-0735
Mailing Address - Country:US
Mailing Address - Phone:321-369-9133
Mailing Address - Fax:888-696-1020
Practice Address - Street 1:6388 SILVER STAR RD STE 1E
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-3235
Practice Address - Country:US
Practice Address - Phone:321-369-9133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA32752225700000X
FLPT21887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891208400Medicaid