Provider Demographics
NPI:1730189697
Name:NDUBISI, BONIFACE U (MD)
Entity type:Individual
Prefix:
First Name:BONIFACE
Middle Name:U
Last Name:NDUBISI
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 1:2964 N STATE ROAD 7
Mailing Address - Street 2:STE 100
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5755
Mailing Address - Country:US
Mailing Address - Phone:954-974-5190
Mailing Address - Fax:954-974-0743
Practice Address - Street 1:2964 N STATE ROAD 7
Practice Address - Street 2:STE 100
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5755
Practice Address - Country:US
Practice Address - Phone:954-974-5190
Practice Address - Fax:954-974-0743
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65086207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
18916OtherBCBS
FL262018900Medicaid
FL18916WMedicare PIN
18916OtherBCBS