Provider Demographics
NPI:1659592970
Name:BONGIORNO, PHILIP ANTHONY (OTR)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:ANTHONY
Last Name:BONGIORNO
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 COUNTRY CLUB DRIVE
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725
Mailing Address - Country:US
Mailing Address - Phone:631-804-1423
Mailing Address - Fax:
Practice Address - Street 1:187 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-4982
Practice Address - Country:US
Practice Address - Phone:516-826-4303
Practice Address - Fax:516-826-9793
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0008341225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist