Basic Information
| Provider Information | |||||||||
| NPI: | 1760461115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONANNO | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 142 BERKELEY ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021165100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172670900 | ||||||||
| FaxNumber: | 6172473460 | ||||||||
| Practice Location | |||||||||
| Address1: | 142 BERKELEY ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021165100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172670900 | ||||||||
| FaxNumber: | 6172473460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 01/26/2012 | ||||||||
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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 | 207R00000X | 74689 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | OJ 11647 | 05 | MA | MEDICAID |