Provider Demographics
NPI:1528123270
Name:BONIFACIO, PHILIP PETER (PHD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:PETER
Last Name:BONIFACIO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 MARK RD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:10598-3525
Mailing Address - Country:US
Mailing Address - Phone:914-419-1748
Mailing Address - Fax:914-245-1541
Practice Address - Street 1:211 W 56TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4312
Practice Address - Country:US
Practice Address - Phone:914-419-1748
Practice Address - Fax:914-245-1541
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4632103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV57851Medicare ID - Type Unspecified