Healthcare Provider Details

I. General information

NPI: 1831271402
Provider Name (Legal Business Name): EUGENE VINCENT BONVENTRE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PENTAGON FLIGHT MEDICINE CLINIC 1760 AIR FORCE PENTAGON ROOM 4A674
WASHINGTON DC
20330-1760
US

IV. Provider business mailing address

2109 12TH PL NW
WASHINGTON DC
20009-7510
US

V. Phone/Fax

Practice location:
  • Phone: 703-697-3255
  • Fax: 703-614-1663
Mailing address:
  • Phone: 703-697-0561
  • Fax: 703-693-0729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: