Basic Information
| Provider Information | |||||||||
| NPI: | 1306289574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONTUMASI | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 S BEACON BLVD STE 160 | ||||||||
| Address2: | |||||||||
| City: | GRAND HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494172654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162682001 | ||||||||
| FaxNumber: | 6162682002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2013 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | R-09922 | IA | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.