Provider Demographics
NPI:1932123031
Name:BONANNI-METKUS, LORETTA (MD)
Entity Type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:
Last Name:BONANNI-METKUS
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 1:795 EAST MARSHALL ST
Mailing Address - Street 2:SUITE 301-307
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380
Mailing Address - Country:US
Mailing Address - Phone:610-429-1100
Mailing Address - Fax:610-429-4848
Practice Address - Street 1:795 EAST MARSHALL ST
Practice Address - Street 2:SUITE 301-307
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380
Practice Address - Country:US
Practice Address - Phone:610-429-1100
Practice Address - Fax:610-429-4848
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-023161-E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103002Medicare ID - Type Unspecified
PAE02316Medicare UPIN