Provider Demographics
NPI:1619918638
Name:BUONOMO, JOHN MARK SR (DO)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARK
Last Name:BUONOMO
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:446 DOMINO LANE
Mailing Address - Street 2:
Mailing Address - City:PHILADEPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128
Mailing Address - Country:US
Mailing Address - Phone:215-483-8666
Mailing Address - Fax:215-483-9616
Practice Address - Street 1:446 DOMINO LANE
Practice Address - Street 2:
Practice Address - City:PHILADEPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128
Practice Address - Country:US
Practice Address - Phone:215-483-8666
Practice Address - Fax:215-483-9616
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006593-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
469539Medicare PIN
E21963Medicare UPIN