Healthcare Provider Details

I. General information

NPI: 1104210053
Provider Name (Legal Business Name): PETER BONGIORNO ND, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HIGH RIDGE RD
STAMFORD CT
06905-1223
US

IV. Provider business mailing address

610 BRETON WAY
GLEN COVE NY
11542-2665
US

V. Phone/Fax

Practice location:
  • Phone: 929-379-0927
  • Fax:
Mailing address:
  • Phone: 917-710-6852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number002612-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT00001298
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number736
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: