Healthcare Provider Details

I. General information

NPI: 1437505963
Provider Name (Legal Business Name): DAYNE KAWIKA BONZO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 CENTRAL AVE # 3349
EIELSON AFB AK
99702-2301
US

IV. Provider business mailing address

2360 CENTRAL AVE #3349 ATTN DR. DAYNE BONZO
EIELSON AFB AK
99702
US

V. Phone/Fax

Practice location:
  • Phone: 907-377-6455
  • Fax:
Mailing address:
  • Phone: 907-377-6455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number199028
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number34.013112
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34.013112
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: