Individual
DR. BONIFASIYO K. SSENNYAMANTONO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
10815 W MCDOWELL RD, SUITE 202, AVONDALE, AZ 85392-5007
(623) 433-0202
(623) 433-0206
Mailing address
3815 E BELL RD STE 4500, PHOENIX, AZ 85032-2171
(602) 633-3848
(602) 633-3841
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
35788
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
129134
—
AZ
Enumeration date
08/02/2006
Last updated
07/31/2024
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