Provider Demographics
NPI:1497957575
Name:BONFANTE, ESTEBAN L (MD)
Entity Type:Individual
Prefix:
First Name:ESTEBAN
Middle Name:L
Last Name:BONFANTE
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 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4127
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:8331 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6094
Practice Address - Country:US
Practice Address - Phone:850-505-4700
Practice Address - Fax:850-505-4711
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1347672080P0206X
AL281272080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009910442Medicaid
AL51542354OtherBCBS
FL279116100Medicaid
FL023485000Medicaid
MS03288866Medicaid