Basic Information
| Provider Information | |||||||||
| NPI: | 1790973147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONITA | ||||||||
| FirstName: | RAPHAEL | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 OLD YORK ROAD | ||||||||
| Address2: | KORMAN, SUITE 202 | ||||||||
| City: | PHIALDELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154562630 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 925 CHESTNUT ST | ||||||||
| Address2: | MEZZANINE LEVEL | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159555050 | ||||||||
| FaxNumber: | 2159551174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2007 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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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 | 207RC0000X | MD428378 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1024344320001 | 05 | PA | MEDICAID | 0225088 | 05 | NJ | MEDICAID |