1265541395 NPI number — DR. JOHN JOSEPH BONACORSI M.D.

Table of content: DR. JOHN JOSEPH BONACORSI M.D. (NPI 1265541395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265541395 NPI number — DR. JOHN JOSEPH BONACORSI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONACORSI
Provider First Name:
JOHN
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265541395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12277 DE PAUL DR
Provider Second Line Business Mailing Address:
STE. 502S
Provider Business Mailing Address City Name:
BRIDGETON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63044-2516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12277 DE PAUL DR
Provider Second Line Business Practice Location Address:
STE. 502S
Provider Business Practice Location Address City Name:
BRIDGETON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63044-2516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-291-5307
Provider Business Practice Location Address Fax Number:
314-291-0838
Provider Enumeration Date:
08/30/2006

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: 174400000X , with the licence number:  R5611 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200165504 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001013172 . This is a "PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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