Basic Information
| Provider Information | |||||||||
| NPI: | 1073537767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONASERA | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1205 FRANKLIN AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115301600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162220067 | ||||||||
| FaxNumber: | 5162220071 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 FRANKLIN AVE STE 150 | ||||||||
| Address2: | |||||||||
| City: | GARDEN CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162220067 | ||||||||
| FaxNumber: | 5162220071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 237615-1 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 237615 | 01 | NY | LICENSE # | OTHER | FB 0033 059 | 01 | NY | DEA # | OTHER |