Healthcare Provider Details

I. General information

NPI: 1568556629
Provider Name (Legal Business Name): VINCENT R BONAGURA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 NORTHERN BLVD SUITE 101
GREAT NECK NY
11021-5310
US

IV. Provider business mailing address

175 COMMUNITY DR 2ND FLOOR
GREAT NECK NY
11021-5502
US

V. Phone/Fax

Practice location:
  • Phone: 516-622-5070
  • Fax: 516-622-5060
Mailing address:
  • Phone: 516-465-1900
  • Fax: 516-465-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number127269
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: