Provider Demographics
NPI:1457622557
Name:BON IMAGE LLC
Entity Type:Organization
Organization Name:BON IMAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NARENDRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:SASTRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-786-0322
Mailing Address - Street 1:15439 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6113
Mailing Address - Country:US
Mailing Address - Phone:352-593-4194
Mailing Address - Fax:352-593-5828
Practice Address - Street 1:15439 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6113
Practice Address - Country:US
Practice Address - Phone:352-593-4194
Practice Address - Fax:352-593-5828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63006208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371150100Medicaid
FL064781100Medicaid
FL006434900Medicaid
FLE85126Medicare UPIN
FL18090WMedicare PIN
330004606Medicare PIN
FLC95307Medicare UPIN