MEDICARE: PHILIP BONANNO M.D.

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	207W00000X	Ophthalmology Physician	124617	NY

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	:	1609867845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP BONANNO M.D.

Provider Business Mailing Address
First Line	:	70 GLEN ST STE 380
Second Line	:
City	:	GLEN COVE
State	:	NY
Zip	:	11542-2858
Country	:	US
Telephone Number	:	516-671-5676
Fax Number	:

Provider Business Practice Location Address
First Line	:	70 GLEN ST STE 380
Second Line	:
City	:	GLEN COVE
State	:	NY
Zip	:	11542-2858
Country	:	US
Telephone Number	:	516-671-5676
Fax Number	:

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

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	07/31/2014

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