Provider Demographics
NPI:1093770042
Name:BONLIE, WAYNE RUSSSELL (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:RUSSSELL
Last Name:BONLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30 E PADONIA RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-2345
Mailing Address - Country:US
Mailing Address - Phone:410-560-7404
Mailing Address - Fax:443-588-1725
Practice Address - Street 1:30 E PADONIA RD
Practice Address - Street 2:SUITE 305
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2345
Practice Address - Country:US
Practice Address - Phone:410-560-7404
Practice Address - Fax:443-588-1725
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0062606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD150010ZDDBMedicare PIN
MDF61293Medicare UPIN
MD945LL573Medicare PIN