Provider Demographics
NPI:1902813678
Name:SSENNYAMANTONO, BONIFASIYO K (MD)
Entity Type:Individual
Prefix:DR
First Name:BONIFASIYO
Middle Name:K
Last Name:SSENNYAMANTONO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:10815 W MCDOWELL RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-5007
Mailing Address - Country:US
Mailing Address - Phone:623-433-0202
Mailing Address - Fax:623-433-0206
Practice Address - Street 1:10815 W MCDOWELL RD
Practice Address - Street 2:SUITE 202
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5007
Practice Address - Country:US
Practice Address - Phone:623-433-0202
Practice Address - Fax:623-433-0206
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2019-04-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ35788207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ129134Medicaid
AZ129134Medicaid
AZZ120433Medicare PIN