Provider Demographics
NPI:1588891584
Name:BONNEVIE, ROBERTO M JR (PT)
Entity type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:M
Last Name:BONNEVIE
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11325 PEMBROOKE SQ STE 115
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20603-4807
Mailing Address - Country:US
Mailing Address - Phone:301-719-1146
Mailing Address - Fax:301-645-5343
Practice Address - Street 1:11325 PEMBROOKE SQ STE 115
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4807
Practice Address - Country:US
Practice Address - Phone:301-358-6155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD584102000Medicaid