Provider Demographics
NPI:1992801492
Name:BUONOCORE, JOHN ANTHONY (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTHONY
Last Name:BUONOCORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4736
Mailing Address - Country:US
Mailing Address - Phone:260-267-9498
Mailing Address - Fax:
Practice Address - Street 1:3005 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4736
Practice Address - Country:US
Practice Address - Phone:260-267-9498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182693207L00000X, 208VP0014X
MI5101020847208VP0014X
OH3411255208VP0014X
IN02004457A207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1992801492Medicaid
OH0103569Medicaid
NYF99492Medicare UPIN
MI1992801492Medicaid
OH0103569Medicaid
31B671Medicare PIN