Provider Demographics
NPI:1629191754
Name:BONGIOVI, MARY ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:BONGIOVI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:BONGIOVI-GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD PHD
Mailing Address - Street 1:400 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:10533
Mailing Address - Country:US
Mailing Address - Phone:914-478-0309
Mailing Address - Fax:
Practice Address - Street 1:1051 RIVERSIDE DR
Practice Address - Street 2:UNIT 105
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-543-5636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1861042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG0131Medicare UPIN
NY8778696504Medicare ID - Type Unspecified