Individual
EDGAR BONCHITA GANTALAO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
635 MAPLE AVE, DU BOIS, PA 15801-2376
(814) 375-6379
(814) 375-9320
Mailing address
100 HOSPITAL AVE, DU BOIS, PA 15801-1440
(814) 375-6379
(814) 375-9320
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
MD418498
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001424280
HIGHMARK BC/BS
PA
05
—
0019070610006
—
PA
Enumeration date
07/04/2006
Last updated
09/06/2012
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