Provider Demographics
NPI:1023162633
Name:DIBONAVENTURA, MARCO (AP, PHD)
Entity type:Individual
Prefix:DR
First Name:MARCO
Middle Name:
Last Name:DIBONAVENTURA
Suffix:
Gender:M
Credentials:AP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 VALLEY FORGE CIR STE 105
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-4527
Mailing Address - Country:US
Mailing Address - Phone:484-392-7023
Mailing Address - Fax:484-392-7877
Practice Address - Street 1:1000 VALLEY FORGE CIR STE 105
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406
Practice Address - Country:US
Practice Address - Phone:484-392-7023
Practice Address - Fax:484-392-7877
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1018171100000X
PAAK001027171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593510229OtherTAX ID