Provider Demographics
NPI:1720080864
Name:BONANNI, FERNANDO B JR (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:B
Last Name:BONANNI
Suffix:JR
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 1:1107 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2600
Mailing Address - Country:US
Mailing Address - Phone:215-206-9679
Mailing Address - Fax:217-214-5805
Practice Address - Street 1:1107 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2600
Practice Address - Country:US
Practice Address - Phone:217-214-5800
Practice Address - Fax:217-214-5805
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD048271L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G03479Medicare UPIN
PA650067Medicare PIN