Provider Demographics
NPI:1073554267
Name:SMITH, BONNIE R (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
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:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-556-7755
Mailing Address - Fax:576-761-3599
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-556-7755
Practice Address - Fax:573-761-3599
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050208532085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00317767OtherRAILROAD MEDICARE
MO751486OtherHEALTHLINK
MO200396604Medicaid
MOP00317767OtherRAILROAD MEDICARE
MOI51423Medicare UPIN