Provider Demographics
NPI:1841374352
Name:BONASERA, GREGORY N (DC)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:N
Last Name:BONASERA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-6000
Mailing Address - Country:US
Mailing Address - Phone:631-445-1011
Mailing Address - Fax:631-642-1070
Practice Address - Street 1:1041 ROUTE 112
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-6000
Practice Address - Country:US
Practice Address - Phone:631-828-4545
Practice Address - Fax:631-642-1070
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005301111N00000X
NYX005301-1111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Not Answered111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01738361Medicaid
NY01738361Medicaid