Provider Demographics
NPI:1255921318
Name:BONITA BEACH MEDICAL GROUP LLC
Entity type:Organization
Organization Name:BONITA BEACH MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BOGDAN-GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COZMUTA
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:203-558-0836
Mailing Address - Street 1:3431 BONITA BEACH RD UNIT 406
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4153
Mailing Address - Country:US
Mailing Address - Phone:239-888-9818
Mailing Address - Fax:239-326-0467
Practice Address - Street 1:3431 BONITA BEACH RD UNIT 406
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4153
Practice Address - Country:US
Practice Address - Phone:239-888-9818
Practice Address - Fax:239-326-0467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty