Provider Demographics
NPI:1942513288
Name:BONIFIELD, DANIEL RYAN (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RYAN
Last Name:BONIFIELD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3704 NORTH BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3658
Mailing Address - Country:US
Mailing Address - Phone:318-442-8399
Mailing Address - Fax:
Practice Address - Street 1:3704 NORTH BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3658
Practice Address - Country:US
Practice Address - Phone:318-442-8399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3003052085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2406094Medicaid