Basic Information
| Provider Information | |||||||||
| NPI: | 1588891584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONNEVIE | ||||||||
| FirstName: | ROBERTO | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5801 ALLENTOWN RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SUITLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207464561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2408421435 | ||||||||
| FaxNumber: | 2403182232 | ||||||||
| Practice Location | |||||||||
| Address1: | 5801 ALLENTOWN RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SUITLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207464561 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2408421435 | ||||||||
| FaxNumber: | 2403182232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2009 | ||||||||
| LastUpdateDate: | 11/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 18452 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 584102000 | 05 | MD | MEDICAID |