Provider Demographics
NPI:1881760205
Name:BONARRIGO, PAUL V (LPT, PC)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:V
Last Name:BONARRIGO
Suffix:
Gender:M
Credentials:LPT, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 E VILLA MARIA RD # A
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-2541
Mailing Address - Country:US
Mailing Address - Phone:979-776-2225
Mailing Address - Fax:979-776-7945
Practice Address - Street 1:2011 E VILLA MARIA RD # A
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2541
Practice Address - Country:US
Practice Address - Phone:979-776-2225
Practice Address - Fax:979-776-7945
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1005635174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8AJ910OtherBLUE CROSS
TX514242Medicare UPIN
TX650087Medicare ID - Type Unspecified