Healthcare Provider Details

I. General information

NPI: 1710894423
Provider Name (Legal Business Name): JASON CARL BONAVITO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 N HIGHWAY 17
MOUNT PLEASANT SC
29466-9123
US

IV. Provider business mailing address

1512 CYPRESS POINTE DR
MOUNT PLEASANT SC
29466-8713
US

V. Phone/Fax

Practice location:
  • Phone: 843-606-7643
  • Fax:
Mailing address:
  • Phone: 631-987-2427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number171620
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: