Provider Demographics
NPI:1598759763
Name:BONURA, JOSEPH WILLIAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:WILLIAM
Last Name:BONURA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 GATEWAY CIRCLE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4085
Mailing Address - Country:US
Mailing Address - Phone:904-318-2088
Mailing Address - Fax:904-823-8873
Practice Address - Street 1:140 GATEWAY CIRCLE
Practice Address - Street 2:SUITE 3
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4085
Practice Address - Country:US
Practice Address - Phone:904-318-2088
Practice Address - Fax:904-823-8873
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 2739213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390438500Medicaid
FLU71366Medicare UPIN
FLE1026AMedicare ID - Type Unspecified