Provider Demographics
NPI:1851912497
Name:BONFIGLIO, GENNARO R (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:GENNARO
Middle Name:R
Last Name:BONFIGLIO
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 MAMARONECK AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-2430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 MAMARONECK AVE STE 200
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-2430
Practice Address - Country:US
Practice Address - Phone:800-321-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0030302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer