Provider Demographics
NPI:1932383056
Name:GABRIELLA BONOMO, MD, PA
Entity Type:Organization
Organization Name:GABRIELLA BONOMO, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONOMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-799-3770
Mailing Address - Street 1:500 UNIVERSITY BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-2773
Mailing Address - Country:US
Mailing Address - Phone:561-799-3770
Mailing Address - Fax:561-799-3776
Practice Address - Street 1:500 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-2773
Practice Address - Country:US
Practice Address - Phone:561-799-3770
Practice Address - Fax:561-799-3776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86702207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7544Medicare PIN