Provider Demographics
NPI:1003928326
Name:MARK D BONNEN MD PA
Entity Type:Organization
Organization Name:MARK D BONNEN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:BONNEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-297-9268
Mailing Address - Street 1:900 N BELLE DR
Mailing Address - Street 2:
Mailing Address - City:ANGLETON
Mailing Address - State:TX
Mailing Address - Zip Code:77515-3397
Mailing Address - Country:US
Mailing Address - Phone:979-848-1365
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL DR # B
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5674
Practice Address - Country:US
Practice Address - Phone:979-297-9268
Practice Address - Fax:979-297-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7985174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI05029Medicare UPIN