Provider Demographics
NPI:1487773669
Name:BONACQUISTI, KEITH ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ANTHONY
Last Name:BONACQUISTI
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 1:1612 CADENCE LOOP
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-4737
Mailing Address - Country:US
Mailing Address - Phone:314-210-5085
Mailing Address - Fax:
Practice Address - Street 1:4021 AVENUE B
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4602
Practice Address - Country:US
Practice Address - Phone:308-630-1885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NECP1177207Y00000X
IL036127592207Y00000X
MO109503207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208534602Medicaid
MO000000466Medicare PIN
MOG-20715Medicare UPIN