Provider Demographics
NPI:1689606477
Name:BONITATIBUS, ANTHONY J (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:BONITATIBUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 NOBLE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4991
Mailing Address - Country:US
Mailing Address - Phone:907-458-2635
Mailing Address - Fax:907-459-3541
Practice Address - Street 1:1001 NOBLE ST STE 1
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4991
Practice Address - Country:US
Practice Address - Phone:907-458-2635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA51624207K00000X
MN45670207K00000X
AK166113207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN550638700Medicaid
GA003121233AMedicaid
AK1714176Medicaid