Provider Demographics
NPI:1942513288
Name:BONIFIELD, DANIEL RYAN (DO)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:RYAN
Last Name:BONIFIELD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 S WASHINGTON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2991
Mailing Address - Country:US
Mailing Address - Phone:307-265-1620
Mailing Address - Fax:307-237-1074
Practice Address - Street 1:419 S WASHINGTON ST STE 101
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2951
Practice Address - Country:US
Practice Address - Phone:307-265-1620
Practice Address - Fax:307-237-1074
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00657912085R0202X
WY14070A2085R0202X, 2085R0204X
NECOPS1262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2406094Medicaid