Provider Demographics
NPI:1881652311
Name:BONACQUISTI, GARY A (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:BONACQUISTI
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 1:1005 W RALPH HALL PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-6663
Mailing Address - Country:US
Mailing Address - Phone:972-771-8686
Mailing Address - Fax:972-771-8687
Practice Address - Street 1:1005 W RALPH HALL PKWY STE 101
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6663
Practice Address - Country:US
Practice Address - Phone:972-771-8686
Practice Address - Fax:972-771-8687
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX039772102Medicaid
TX039772103Medicaid
TX039772103Medicaid
TX8G7247Medicare PIN
TXF47149Medicare UPIN