Provider Demographics
NPI:1871975383
Name:BONAFEDE, LUCAS (MD)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:
Last Name:BONAFEDE
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 1:33080 UTICA RD STE B
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-2038
Mailing Address - Country:US
Mailing Address - Phone:586-296-7250
Mailing Address - Fax:
Practice Address - Street 1:33080 UTICA RD STE B
Practice Address - Street 2:
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026-2038
Practice Address - Country:US
Practice Address - Phone:586-296-7250
Practice Address - Fax:586-296-0276
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301502199207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-1359063OtherEMPLOYEE IDENTIFICATION NUMBER