1033255575 NPI number — MR. MATTHEW RONALD DE BONA AP, DOM, L.AP

Table of content: MR. MATTHEW RONALD DE BONA AP, DOM, L.AP (NPI 1033255575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033255575 NPI number — MR. MATTHEW RONALD DE BONA AP, DOM, L.AP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE BONA
Provider First Name:
MATTHEW
Provider Middle Name:
RONALD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
AP, DOM, L.AP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DE BONA
Provider Other First Name:
MATTHEW
Provider Other Middle Name:
RONALD
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AP, DOM, L.AP,
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1033255575
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5344 9TH ST STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZEPHYRHILLS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33542-4348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-588-2028
Provider Business Mailing Address Fax Number:
813-434-2277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5344 9TH ST STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZEPHYRHILLS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33542-4348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-588-2028
Provider Business Practice Location Address Fax Number:
813-434-2277
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AP1555 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 111749000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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