Provider Demographics
NPI:1790787372
Name:BONFILIO, NICHOLAS D (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:D
Last Name:BONFILIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1400 29TH ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5353
Mailing Address - Country:US
Mailing Address - Phone:406-454-2171
Mailing Address - Fax:406-771-3021
Practice Address - Street 1:3000 15TH AVE S
Practice Address - Street 2:GREAT FALLS CLINIC
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405
Practice Address - Country:US
Practice Address - Phone:406-454-2171
Practice Address - Fax:406-771-3021
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT7695207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0106379Medicaid
MT0106379Medicaid
MT010000841Medicare ID - Type Unspecified