Provider Demographics
NPI:1558464578
Name:ENGELBART, BONNIE (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:ENGELBART
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 1:454 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:01901
Mailing Address - Country:US
Mailing Address - Phone:781-485-8222
Mailing Address - Fax:781-485-8220
Practice Address - Street 1:454 BROADWAY
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:01901
Practice Address - Country:US
Practice Address - Phone:781-485-8222
Practice Address - Fax:781-485-8220
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215224207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2148960Medicaid
MAA3413901Medicare PIN
H53933Medicare UPIN