Provider Demographics
NPI:1184721227
Name:LISA M. BONAVENTURA, M.D., P.A.
Entity type:Organization
Organization Name:LISA M. BONAVENTURA, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P.A. PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BONAVENTURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-781-9661
Mailing Address - Street 1:2345 LAMINGTON RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BEDMINSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07921-2612
Mailing Address - Country:US
Mailing Address - Phone:908-781-9661
Mailing Address - Fax:908-781-2106
Practice Address - Street 1:2345 LAMINGTON RD
Practice Address - Street 2:SUITE 104
Practice Address - City:BEDMINSTER
Practice Address - State:NJ
Practice Address - Zip Code:07921-2612
Practice Address - Country:US
Practice Address - Phone:908-781-9661
Practice Address - Fax:908-781-2106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA51694207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty