Provider Demographics
NPI:1508318841
Name:FEDERMAN, BONNIE (MD, CGC)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:FEDERMAN
Suffix:
Gender:F
Credentials:MD, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11205 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-8311
Mailing Address - Country:US
Mailing Address - Phone:718-670-1322
Mailing Address - Fax:
Practice Address - Street 1:11205 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-8311
Practice Address - Country:US
Practice Address - Phone:718-670-1322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-03
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166017207R00000X
170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No170300000XOther Service ProvidersGenetic Counselor, MSGroup - Single Specialty