Provider Demographics
NPI:1568556629
Name:BONAGURA, VINCENT R (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:R
Last Name:BONAGURA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:175 COMMUNITY DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5502
Mailing Address - Country:US
Mailing Address - Phone:516-465-1900
Mailing Address - Fax:516-465-1830
Practice Address - Street 1:865 NORTHERN BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5310
Practice Address - Country:US
Practice Address - Phone:516-622-5070
Practice Address - Fax:516-622-5060
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1272692080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00828937Medicaid
B17087Medicare UPIN
06321Medicare ID - Type Unspecified
61A461Medicare ID - Type Unspecified