Provider Demographics
NPI:1508419771
Name:BONISTALLI, GREGORY STEPHEN (AUD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:STEPHEN
Last Name:BONISTALLI
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 LONG BEACH RD
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-4107
Mailing Address - Country:US
Mailing Address - Phone:516-208-2000
Mailing Address - Fax:516-208-2004
Practice Address - Street 1:3181 LONG BEACH RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-4107
Practice Address - Country:US
Practice Address - Phone:516-208-2000
Practice Address - Fax:516-208-2004
Is Sole Proprietor?:No
Enumeration Date:2019-07-17
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14000057896237600000X
NY15000057896237600000X
NY002865231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05808177Medicaid