Healthcare Provider Details

I. General information

NPI: 1184885329
Provider Name (Legal Business Name): VALERIE BONICA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S BROAD ST 3RD FLOOR
PHILADELPHIA PA
19146-1613
US

IV. Provider business mailing address

321 W GIRARD AVE
PHILADELPHIA PA
19123-1531
US

V. Phone/Fax

Practice location:
  • Phone: 215-685-6790
  • Fax: 215-685-6732
Mailing address:
  • Phone: 215-685-3803
  • Fax: 215-685-3816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT012330
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: