Provider Demographics
NPI:1770599953
Name:BONGIORNO, JEFFREY JOSEPH (DPM)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOSEPH
Last Name:BONGIORNO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2132 WILLOW POND WAY
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9102
Mailing Address - Country:US
Mailing Address - Phone:262-268-1789
Mailing Address - Fax:
Practice Address - Street 1:1317 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2075
Practice Address - Country:US
Practice Address - Phone:262-284-8800
Practice Address - Fax:262-284-8861
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI798025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00085509OtherRR MCR
WI41755100Medicaid
WI43227800Medicaid
4998210001OtherDMERC
P00085509OtherRR MCR
WI43227800Medicaid