Healthcare Provider Details

I. General information

NPI: 1720297419
Provider Name (Legal Business Name): JOHN ANTHONY BONINO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 RAINBOW BLVD, RM 4035 WESCOE MAILSTOP 1023
KANSAS CITY KS
66160
US

IV. Provider business mailing address

3901 RAINBOW BLVD, RM 4035 WESCOE MAILSTOP 1023
KANSAS CITY KS
66160
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-6003
  • Fax: 913-588-3975
Mailing address:
  • Phone: 913-588-6003
  • Fax: 913-588-3975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number04-30674
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: