Provider Demographics
NPI:1992771349
Name:BONOMINI, LUIGI VITTORIO (MD)
Entity type:Individual
Prefix:DR
First Name:LUIGI
Middle Name:VITTORIO
Last Name:BONOMINI
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 1:767 NORTHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1194
Mailing Address - Country:US
Mailing Address - Phone:973-419-0417
Mailing Address - Fax:862-766-5904
Practice Address - Street 1:767 NORTHFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1194
Practice Address - Country:US
Practice Address - Phone:973-419-0417
Practice Address - Fax:862-766-5904
Is Sole Proprietor?:No
Enumeration Date:2006-02-26
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA064708000207R00000X
NY1932-29207R00000X, 207RN0300X
NJ25MA06470800207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7551401Medicaid
NJ463306S8AMedicare ID - Type Unspecified
NJ7551401Medicaid