Provider Demographics
NPI:1306289574
Name:BONTUMASI, NICHOLAS MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MICHAEL
Last Name:BONTUMASI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:1600 S BEACON BLVD STE 160
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2654
Practice Address - Country:US
Practice Address - Phone:616-268-2001
Practice Address - Fax:616-268-2002
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IAR-09922207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology