Provider Demographics
NPI:1093015844
Name:BONNER, MACK (MD)
Entity Type:Individual
Prefix:DR
First Name:MACK
Middle Name:
Last Name:BONNER
Suffix:
Gender:M
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 1500
Mailing Address - Street 2:
Mailing Address - City:BUTNER
Mailing Address - State:NC
Mailing Address - Zip Code:27509-4500
Mailing Address - Country:US
Mailing Address - Phone:919-575-3900
Mailing Address - Fax:
Practice Address - Street 1:OLD RTE 75
Practice Address - Street 2:FEDERAL MEDICAL CENTER,
Practice Address - City:BUTNER
Practice Address - State:NC
Practice Address - Zip Code:27509-4500
Practice Address - Country:US
Practice Address - Phone:919-575-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231922207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine