Provider Demographics
NPI:1720256043
Name:BONITA M MANCIA M.D.
Entity Type:Organization
Organization Name:BONITA M MANCIA M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MANCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-288-6521
Mailing Address - Street 1:676 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3857
Mailing Address - Country:US
Mailing Address - Phone:570-288-6521
Mailing Address - Fax:
Practice Address - Street 1:676 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3857
Practice Address - Country:US
Practice Address - Phone:570-288-6521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD022345E207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0013981600001Medicaid
PAC29346Medicare UPIN