Basic Information
Provider Information | |||||||||
NPI: | 1215227004 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BONTA | ||||||||
FirstName: | ALYSSA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 PRESTIGE PL STE 550 | ||||||||
Address2: |   | ||||||||
City: | MIAMISBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 453426115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9377621310 | ||||||||
FaxNumber: | 9375228493 | ||||||||
Practice Location | |||||||||
Address1: | 1 ELIZABETH PL STE 10A | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 45417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9372284126 | ||||||||
FaxNumber: | 9372280247 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2011 | ||||||||
LastUpdateDate: | 11/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 35.122523 | OH | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0129X | 35.122523 | OH | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | H618980 | 01 |   | MEDICARE | OTHER | 0279347 | 05 | OH |   | MEDICAID |