John Joseph Bonacorsi, M.D.

Primary specialty

SpecialistTaxonomy code 174400000X

License

R5611 Issued in MO

Practice address

12277 De Paul Dr
Ste. 502S
Bridgeton, MO 63044-2516

Phone

(314) 291-5307

Fax

(314) 291-0838

NPI assigned

Aug 30, 2006

Sex

Male

Sole proprietor

No

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Northwest Otolaryngology, Inc

  • Specialist
  • Bridgeton, MO
  • NPI 1578747408
  NPD (past)

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Sep 14, 2011.

{
    "created_epoch": "1156896000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1315958400000",
    "number": "1265541395",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12277 DE PAUL DR",
            "address_2": "STE. 502S",
            "city": "BRIDGETON",
            "state": "MO",
            "postal_code": "630442516"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12277 DE PAUL DR",
            "address_2": "STE. 502S",
            "city": "BRIDGETON",
            "state": "MO",
            "postal_code": "630442516",
            "telephone_number": "314-291-5307",
            "fax_number": "314-291-0838"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BONACORSI",
        "first_name": "JOHN",
        "middle_name": "JOSEPH",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-08-30",
        "last_updated": "2011-09-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "MO",
            "license": "R5611",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200165504",
            "state": "MO"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN",
            "identifier": "001013172",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Bridgette Bobo, LCSW
• Thomas P Bocchini, MD
• Gerard William Boehmer, D.C.
• Elizabeth Bokermann, PA
• Sarah Bolton, OTR/L
• Robert L Bonsanti, M.D.
• Chotchai Boonkham, M.D.
• Je'an-Claude Dalton Bordeaux, D.C.
• Tanya Lynn Borowiak
• Larry L Borth, DDS

• All providers in Bridgeton, MO
• Specialist in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 14, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.