Provider Demographics
NPI:1316900657
Name:BONAMO, JOEL R (MD)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:R
Last Name:BONAMO
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 1:1551 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304
Mailing Address - Country:US
Mailing Address - Phone:718-351-6500
Mailing Address - Fax:718-351-7672
Practice Address - Street 1:1551 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304
Practice Address - Country:US
Practice Address - Phone:718-351-6500
Practice Address - Fax:718-351-7672
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132853207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
C10062Medicare UPIN
45A11100Medicare ID - Type Unspecified