Provider Demographics
NPI:1861647893
Name:ROGER A BONOMO,MD,PC
Entity Type:Organization
Organization Name:ROGER A BONOMO,MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:A
Authorized Official - Last Name:BONOMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-688-3443
Mailing Address - Street 1:47 E 77TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1730
Mailing Address - Country:US
Mailing Address - Phone:646-688-3443
Mailing Address - Fax:
Practice Address - Street 1:47 E 77TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1730
Practice Address - Country:US
Practice Address - Phone:646-688-3443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1389242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty