Healthcare Provider Details

I. General information

NPI: 1386934917
Provider Name (Legal Business Name): GIOVANNI BONOMO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2011
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 MASON AVE BLDG C3
STATEN ISLAND NY
10305-3408
US

IV. Provider business mailing address

256 MASON AVE BLDG C3
STATEN ISLAND NY
10305-3408
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-6398
  • Fax:
Mailing address:
  • Phone: 718-226-6398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number297392-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: