Healthcare Provider Details

I. General information

NPI: 1528232394
Provider Name (Legal Business Name): ALEXIS BONEPARTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3959 BROADWAY
NEW YORK NY
10032-1559
US

IV. Provider business mailing address

3959 BROADWAY # 7C
NEW YORK NY
10032-1559
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-9304
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number247973
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number25MA09256300
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number247973
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: