Provider Demographics
NPI:1083785208
Name:NICKLAS, BONNIE JOHNG (DPM)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:JOHNG
Last Name:NICKLAS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:BONNIE
Other - Middle Name:JOHNG
Other - Last Name:NICKLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:7816 DORVER AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-5842
Mailing Address - Country:US
Mailing Address - Phone:216-441-5523
Mailing Address - Fax:
Practice Address - Street 1:10701 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1702
Practice Address - Country:US
Practice Address - Phone:216-791-3800
Practice Address - Fax:216-421-3038
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36 002263213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist