Provider Demographics
NPI:1982641635
Name:BOVIENZO, JAMES D (DO)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:D
Last Name:BOVIENZO
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 1:100 W 58TH ST
Mailing Address - Street 2:APT 6F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2129
Mailing Address - Country:US
Mailing Address - Phone:203-576-5177
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:ST. VINCENT'S MEDICAL CENTER
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4201
Practice Address - Country:US
Practice Address - Phone:203-576-5177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA160395207P00000X
KY02816207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100050090Medicaid
KY000000569669OtherANTHEM BCBS
KY000000569669OtherANTHEM BCBS
KY00280079Medicare PIN