Healthcare Provider Details

I. General information

NPI: 1831138841
Provider Name (Legal Business Name): RAYMOND JOHN BONIFACE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 BELMONT AVE FL 2
YOUNGSTOWN OH
44504-1006
US

IV. Provider business mailing address

1044 BELMONT AVE FL 2
YOUNGSTOWN OH
44504-1006
US

V. Phone/Fax

Practice location:
  • Phone: 330-480-3990
  • Fax: 330-480-3522
Mailing address:
  • Phone: 330-480-3990
  • Fax: 330-480-3522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOH35056633
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: