Provider Demographics
NPI:1215390455
Name:MARMORA, BONNIE (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:MARMORA
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 1:4881 SUGAR MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:WRIGHT PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5529
Mailing Address - Country:US
Mailing Address - Phone:937-257-0837
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45433-5529
Practice Address - Country:US
Practice Address - Phone:937-257-0837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301500857207P00000X
MI4351037703207P00000X
MI5315083941207P00000X
390200000X
OH35.141356207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program