Healthcare Provider Details

I. General information

NPI: 1447740014
Provider Name (Legal Business Name): CHARLES BONANNO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2685 EXECUTIVE PARK DR STE 5
WESTON FL
33331-3651
US

IV. Provider business mailing address

2685 EXECUTIVE PARK DR STE 5
WESTON FL
33331-3651
US

V. Phone/Fax

Practice location:
  • Phone: 954-590-0556
  • Fax:
Mailing address:
  • Phone: 954-590-0556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME148408
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number148408
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME148408
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: