Provider Demographics
NPI:1073673760
Name:BONEBRAKE, PORTIA (MD)
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:BONEBRAKE
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 1:2542 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5216
Mailing Address - Country:US
Mailing Address - Phone:773-365-7277
Mailing Address - Fax:773-365-3091
Practice Address - Street 1:2542 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5216
Practice Address - Country:US
Practice Address - Phone:773-365-7277
Practice Address - Fax:773-365-3091
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1126022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-112602OtherSTATE LICENSE NUMBER
036112602OtherBLUE SHIELD
IL036112602Medicaid
IL036-112602OtherSTATE LICENSE NUMBER