Healthcare Provider Details

I. General information

NPI: 1992789754
Provider Name (Legal Business Name): EDWARD J BONGIORNO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 COMMANCHE AVE
GREEN BAY WI
54313-5753
US

IV. Provider business mailing address

1630 COMMANCHE AVE
GREEN BAY WI
54313-5753
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-4700
  • Fax:
Mailing address:
  • Phone: 920-430-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45808
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4508
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number45808
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: