Provider Demographics
NPI:1104921527
Name:BONGIOVI, RAYMOND (DC)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:
Last Name:BONGIOVI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-2616
Mailing Address - Country:US
Mailing Address - Phone:732-574-2225
Mailing Address - Fax:732-574-0227
Practice Address - Street 1:764 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-2616
Practice Address - Country:US
Practice Address - Phone:732-574-2225
Practice Address - Fax:732-574-0227
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00386800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ647017Medicare ID - Type Unspecified
NJ223712063Medicare UPIN