MEDICARE: DANIEL L BONIFACIO D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	5101011505	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033104880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL L BONIFACIO D.O.

Provider Business Mailing Address
First Line	:	2891 MOMENTUM PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60689-5328
Country	:	US
Telephone Number	:	231-935-6080
Fax Number	:	231-935-6081

Provider Business Practice Location Address
First Line	:	1200 SIXTH ST
Second Line	:	SUITE 200
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2369
Country	:	US
Telephone Number	:	231-935-5800
Fax Number	:	231-935-5799

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	07/21/2022

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