Provider Demographics
NPI:1316094428
Name:BONVINO, STEVEN (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:BONVINO
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:ONE EDGEWATER STREET
Mailing Address - Street 2:SUITE 723
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305
Mailing Address - Country:US
Mailing Address - Phone:718-226-4324
Mailing Address - Fax:718-226-1039
Practice Address - Street 1:375 SEGUINE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309
Practice Address - Country:US
Practice Address - Phone:718-226-9488
Practice Address - Fax:718-226-8132
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213748207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01974134Medicaid
NY01974134Medicaid
NY50C551Medicare ID - Type Unspecified