1407891609 NPI number — MARIE L BONVICINO M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407891609 NPI number — MARIE L BONVICINO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONVICINO
Provider First Name:
MARIE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1407891609
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 OAK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOMS RIVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08753-3348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-914-1919
Provider Business Mailing Address Fax Number:
732-341-3303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 OAK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOMS RIVER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08753-3348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-914-1919
Provider Business Practice Location Address Fax Number:
732-341-3303
Provider Enumeration Date:
06/19/2006

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:  25MA06624300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0062754000 . This is a "AMERIHEALTH NJ PA DEL" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3023421 . This is a "CIGNA COMED" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7653506 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: G02909 . This is a "HEALTH NET PHS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P732138 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 010066243NJ01 . This is a "ST BARNABAS HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 341407 . This is a "AMERIHEALTH ADMIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3023421001 . This is a "CIGNA HMO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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