Provider Demographics
NPI:1750472528
Name:BONANNO, RICHARD JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JOSEPH
Last Name:BONANNO
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 1:303 PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:BRIGHTWATERS
Mailing Address - State:NY
Mailing Address - Zip Code:11718-1409
Mailing Address - Country:US
Mailing Address - Phone:631-968-8517
Mailing Address - Fax:
Practice Address - Street 1:1869 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4625
Practice Address - Country:US
Practice Address - Phone:631-853-3458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00352727Medicaid
NY080096384Medicare PIN
NY97371Medicare ID - Type Unspecified
B80260Medicare UPIN