Provider Demographics
NPI:1386607521
Name:BONGO, ELIZABETH (RD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BONGO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 BRANT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1540
Mailing Address - Country:US
Mailing Address - Phone:732-382-0091
Mailing Address - Fax:732-382-8570
Practice Address - Street 1:525 CENTRAL AVE STE D
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-2545
Practice Address - Country:US
Practice Address - Phone:908-389-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP80048Medicare UPIN
NJ066985Medicare ID - Type Unspecified