Healthcare Provider Details

I. General information

NPI: 1942439765
Provider Name (Legal Business Name): ERNESTO BONDAREVSKY M.D. 207R00000X
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 KEREN HAYESOD ST.
RAMAT HASHARON NOT EXISTENT
47248
IL

IV. Provider business mailing address

43 KEREN HAYESOD ST.
RAMAT HASHARON NOT EXISTENT
47248
IL

V. Phone/Fax

Practice location:
  • Phone: 97235490442
  • Fax: 97235490517
Mailing address:
  • Phone: 97235490442
  • Fax: 97235490517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberF4767
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberF4767
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: