Healthcare Provider Details

I. General information

NPI: 1043280456
Provider Name (Legal Business Name): ROBERT WALTER BOHNENBERGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 BARD AVE
STATEN ISLAND NY
10310-1664
US

IV. Provider business mailing address

15 WESTBURY AVE
STATEN ISLAND NY
10301-2025
US

V. Phone/Fax

Practice location:
  • Phone: 718-818-3298
  • Fax:
Mailing address:
  • Phone: 718-447-8665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number169720
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number169720
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: