Healthcare Provider Details

I. General information

NPI: 1649224288
Provider Name (Legal Business Name): JERRY P BONET D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 W 47TH ST
LA GRANGE IL
60525-6136
US

IV. Provider business mailing address

1415 W 47TH ST
LA GRANGE IL
60525-6136
US

V. Phone/Fax

Practice location:
  • Phone: 708-352-5652
  • Fax: 708-352-2105
Mailing address:
  • Phone: 708-352-5652
  • Fax: 708-352-2105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number016-00316-0
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: