Provider Demographics
NPI:1962419085
Name:BONAVENTURA, LEO M (MD)
Entity type:Individual
Prefix:DR
First Name:LEO
Middle Name:M
Last Name:BONAVENTURA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4199 GATEWAY BLVD
Mailing Address - Street 2:SUITE 2900
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8940
Mailing Address - Country:US
Mailing Address - Phone:812-842-4530
Mailing Address - Fax:812-842-4535
Practice Address - Street 1:4199 GATEWAY BLVD
Practice Address - Street 2:SUITE 2900
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8940
Practice Address - Country:US
Practice Address - Phone:812-842-4530
Practice Address - Fax:812-842-4535
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01022970207VG0400X, 207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000328110OtherANTHEM
IN000000580355OtherANTHEM