Provider Demographics
NPI:1881893303
Name:BONCZAK, BOGUSLAW S (MD)
Entity type:Individual
Prefix:DR
First Name:BOGUSLAW
Middle Name:S
Last Name:BONCZAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3715 MUNICIPAL DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-5483
Mailing Address - Country:US
Mailing Address - Phone:815-759-1953
Mailing Address - Fax:224-610-3815
Practice Address - Street 1:3715 MUNICIPAL DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-5483
Practice Address - Country:US
Practice Address - Phone:815-759-1953
Practice Address - Fax:224-610-3815
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125053459207Q00000X
IL036-124359207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036124359OtherSTATE LICENSE