Healthcare Provider Details

I. General information

NPI: 1962419085
Provider Name (Legal Business Name): LEO M. BONAVENTURA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4199 GATEWAY BLVD SUITE 2900
NEWBURGH IN
47630-8940
US

IV. Provider business mailing address

4199 GATEWAY BLVD SUITE 2900
NEWBURGH IN
47630-8940
US

V. Phone/Fax

Practice location:
  • Phone: 812-842-4530
  • Fax: 812-842-4535
Mailing address:
  • Phone: 812-842-4530
  • Fax: 812-842-4535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number01022970
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number01022970
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: