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General NPI Number Information
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NPI Number | 1255921318
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Entity Type | Organization
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Legal Business Name | BONITA BEACH MEDICAL GROUP LLC
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Dates
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Enumeration Date | 01/22/2021
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Last Update Date | 01/22/2021
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Provider Practice Location Address
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Address Line | 3431 BONITA BEACH RD UNIT 406
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City | BONITA SPRINGS
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State | FL
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Zip | 34134-4153
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Country | US
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Telephone | 239-888-9818
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Fax | 239-326-0467
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Provider Business Mailing Address
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Address Line | 3431 BONITA BEACH RD UNIT 406
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City | BONITA SPRINGS
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State | FL
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Zip | 34134-4153
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Country | US
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Telephone | 239-888-9818
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Fax | 239-326-0467
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Authorized Official
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Title or Position | MANAGER
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Name | BOGDAN-GABRIEL COZMUTA
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Credential | PA
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Telephone | 203-558-0836
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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