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General NPI Number Information
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NPI Number | 1376627661
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Entity Type | Individual
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Provider Name | MARY ELIZABETH BONAFEDE M.D.
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Gender | Female
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Dates
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Enumeration Date | 10/24/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 239 HIGBIE LN
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City | WEST ISLIP
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State | NY
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Zip | 11795-2825
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Country | US
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Telephone | 631-376-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 92 S MONTGOMERY AVE
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City | BAY SHORE
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State | NY
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Zip | 11706-8808
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Country | US
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Telephone | 631-969-3865
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0208X
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Taxonomy Name | Pediatric Infectious Diseases Physician
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License Number | 208119
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License Number State | NY
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