Individual
JOHN P BONAVIA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1317 W GRAND AVE, PORT WASHINGTON, WI 53074-2075
(262) 268-6998
Mailing address
4425 N PORT WASHINGTON RD, ATTN: CSMCP CLINIC CREDENTIALING, GLENDALE, WI 53212-1082
(414) 961-2750
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
23729
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
30656000
—
WI
Enumeration date
03/28/2006
Last updated
06/05/2012
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