Healthcare Provider Details

I. General information

NPI: 1376627661
Provider Name (Legal Business Name): MARY ELIZABETH BONAFEDE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 HIGBIE LN
WEST ISLIP NY
11795-2825
US

IV. Provider business mailing address

92 S MONTGOMERY AVE
BAY SHORE NY
11706-8808
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-3000
  • Fax:
Mailing address:
  • Phone: 631-969-3865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number208119
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: