Provider Demographics
NPI:1851460174
Name:BONOMO, ROGER A (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:A
Last Name:BONOMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:47 E 77TH ST STE 201
Mailing Address - Street 2:ROGER A BONOMO MD PC
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1730
Mailing Address - Country:US
Mailing Address - Phone:646-688-3443
Mailing Address - Fax:646-688-4332
Practice Address - Street 1:47 E 77TH ST STE 201
Practice Address - Street 2:ROGER A BONOMO MD PC
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1730
Practice Address - Country:US
Practice Address - Phone:646-688-3443
Practice Address - Fax:646-688-4332
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1389242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B80381Medicare UPIN
NY141N01Medicare ID - Type Unspecified