Provider Demographics
NPI:1487773669
Name:BONACQUISTI, KEITH ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ANTHONY
Last Name:BONACQUISTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 SAINT ANTHONYS WAY
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4569
Mailing Address - Country:US
Mailing Address - Phone:618-462-2277
Mailing Address - Fax:618-463-9342
Practice Address - Street 1:1029 NICHOLS RD STE 301
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3008
Practice Address - Country:US
Practice Address - Phone:573-302-2864
Practice Address - Fax:573-302-2867
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036127592207Y00000X
MO109503207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208534602Medicaid
MO000000466Medicare PIN
MOG-20715Medicare UPIN