Provider Demographics
NPI:1831138841
Name:BONIFACE, RAYMOND JOHN (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:JOHN
Last Name:BONIFACE
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 1:835 MCKAY CT
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5786
Mailing Address - Country:US
Mailing Address - Phone:330-758-4399
Mailing Address - Fax:330-758-8995
Practice Address - Street 1:835 MCKAY CT
Practice Address - Street 2:STE 100
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-5786
Practice Address - Country:US
Practice Address - Phone:330-758-4399
Practice Address - Fax:330-758-8995
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH35056633207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0701182Medicaid
OH0701182Medicaid
OHA82977Medicare UPIN
OH0701182Medicaid