Provider Demographics
NPI:1790973147
Name:BONITA, RAPHAEL EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:EDWARD
Last Name:BONITA
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 1:5501 OLD YORK ROAD
Mailing Address - Street 2:KORMAN, SUITE 202
Mailing Address - City:PHIALDELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3018
Mailing Address - Country:US
Mailing Address - Phone:215-456-2630
Mailing Address - Fax:
Practice Address - Street 1:925 CHESTNUT ST
Practice Address - Street 2:MEZZANINE LEVEL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4216
Practice Address - Country:US
Practice Address - Phone:215-955-5050
Practice Address - Fax:215-955-1174
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428378207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024344320001Medicaid
NJ0225088Medicaid
PA1024344320001Medicaid