Provider Demographics
NPI:1871682575
Name:BONOMO, RITA (MD)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:BONOMO
Suffix:
Gender:F
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:PO BOX 901900
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44190-1900
Mailing Address - Country:US
Mailing Address - Phone:216-464-1115
Mailing Address - Fax:216-464-2930
Practice Address - Street 1:3909 ORANGE PL STE 2400
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4468
Practice Address - Country:US
Practice Address - Phone:216-383-0100
Practice Address - Fax:216-383-6481
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35061227B207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F51805Medicare UPIN