Healthcare Provider Details

I. General information

NPI: 1245442177
Provider Name (Legal Business Name): BONAVENTURA REPRODUCTIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 N ILLINOIS ST STE 345
CARMEL IN
46032-3008
US

IV. Provider business mailing address

11725 N ILLINOIS ST STE 345
CARMEL IN
46032-3008
US

V. Phone/Fax

Practice location:
  • Phone: 317-814-4570
  • Fax: 317-814-4517
Mailing address:
  • Phone: 317-814-4570
  • Fax: 317-814-4517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: LEO BONAVENTURA
Title or Position: OWNER
Credential: MD
Phone: 317-814-4570