Provider Demographics
NPI:1033120993
Name:BONTRAGER, LILLY S (MD)
Entity Type:Individual
Prefix:
First Name:LILLY
Middle Name:S
Last Name:BONTRAGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LILLY
Other - Middle Name:S
Other - Last Name:SANTELIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 E 5TH ST STE 1
Practice Address - Street 2:
Practice Address - City:DELPHOS
Practice Address - State:OH
Practice Address - Zip Code:45833-9180
Practice Address - Country:US
Practice Address - Phone:419-692-5611
Practice Address - Fax:419-695-9401
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061077A207Q00000X
OH35137291207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
22313OtherPHYSICIANS HEALTH PLAN
INP00465447OtherRAILROAD MEDICARE
000000518581OtherBLUE CROSS BLUE SHIELD
IN000000665045OtherANTHEM
000000039572OtherMPLAN
IN200803540Medicaid
000000518581OtherBLUE CROSS BLUE SHIELD
INP00465447OtherRAILROAD MEDICARE
000000039572OtherMPLAN
INI40769Medicare UPIN