Provider Demographics
NPI:1093775397
Name:BONABON, MARIE ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:ROSE
Last Name:BONABON
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 1:800 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3300
Mailing Address - Country:US
Mailing Address - Phone:864-234-5800
Mailing Address - Fax:864-284-0844
Practice Address - Street 1:309 W BUTLER RD
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2531
Practice Address - Country:US
Practice Address - Phone:864-297-1575
Practice Address - Fax:864-284-0844
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23996208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC239969Medicaid
SCH95298Medicare UPIN