Healthcare Provider Details

I. General information

NPI: 1619973534
Provider Name (Legal Business Name): ARNULFO B BONAVENTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6409 CRAIN HWY ROUTE 301
UPPER MARLBORO MD
20772-4139
US

IV. Provider business mailing address

10403 HOSPITAL DR STE G4
CLINTON MD
20735-3137
US

V. Phone/Fax

Practice location:
  • Phone: 301-952-8614
  • Fax: 301-627-1603
Mailing address:
  • Phone: 301-856-3019
  • Fax: 301-856-9370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0045630
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: