Provider Demographics
NPI:1285738625
Name:BONOMO, DANIEL JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JAMES
Last Name:BONOMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 20TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-6523
Mailing Address - Country:US
Mailing Address - Phone:914-552-6842
Mailing Address - Fax:914-560-2121
Practice Address - Street 1:1407 20TH AVE E
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-6523
Practice Address - Country:US
Practice Address - Phone:914-552-6842
Practice Address - Fax:914-560-2121
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME152253207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01045367Medicaid
NYA60222Medicare UPIN
NY01045367Medicaid