Provider Demographics
NPI:1710983192
Name:BONI, DINO R JR (MD)
Entity Type:Individual
Prefix:
First Name:DINO
Middle Name:R
Last Name:BONI
Suffix:JR
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 1:1953 BRUSH RUN RD
Mailing Address - Street 2:
Mailing Address - City:AVELLA
Mailing Address - State:PA
Mailing Address - Zip Code:15312-2004
Mailing Address - Country:US
Mailing Address - Phone:304-233-9314
Mailing Address - Fax:304-233-0265
Practice Address - Street 1:1953 BRUSH RUN RD
Practice Address - Street 2:
Practice Address - City:AVELLA
Practice Address - State:PA
Practice Address - Zip Code:15312-2004
Practice Address - Country:US
Practice Address - Phone:304-233-9314
Practice Address - Fax:304-233-0265
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12108207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3002778000Medicaid
C30820Medicare UPIN
WV4037521Medicare PIN