Healthcare Provider Details

I. General information

NPI: 1457004939
Provider Name (Legal Business Name): JUSTIN BONZATO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 EDGEWOOD RD SW STE 300
CEDAR RAPIDS IA
52404-7205
US

IV. Provider business mailing address

3290 RIDGEWAY DR STE 3
CORALVILLE IA
52241-2023
US

V. Phone/Fax

Practice location:
  • Phone: 319-363-2901
  • Fax: 319-363-2903
Mailing address:
  • Phone: 319-665-2630
  • Fax: 319-665-2631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number111797
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: