Provider Demographics
NPI:1174585954
Name:BONGALOS, JR., CIRIACO G (MD)
Entity type:Individual
Prefix:DR
First Name:CIRIACO
Middle Name:G
Last Name:BONGALOS, JR.
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 S GOVERNORS AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-6901
Mailing Address - Country:US
Mailing Address - Phone:302-734-9150
Mailing Address - Fax:302-734-3931
Practice Address - Street 1:1025 S GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-6901
Practice Address - Country:US
Practice Address - Phone:302-734-9150
Practice Address - Fax:302-734-3931
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10001931207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000088201Medicaid
DE26436OtherCOVENTRY HEALTH CARE
DEAETNAOther18151
DE26436OtherCOVENTRY HEALTH CARE
DE510261029OtherFEDERAL TAX ID NUMBER
DEAETNAOther18151
DEB66493Medicare UPIN