Provider Demographics
NPI:1225080336
Name:BONNER, COURTNEY ANNE (DO)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:ANNE
Last Name:BONNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:COURTNEY
Other - Middle Name:ANNE
Other - Last Name:DESELM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:716 ADAIR AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-2836
Mailing Address - Country:US
Mailing Address - Phone:740-891-9000
Mailing Address - Fax:740-891-9001
Practice Address - Street 1:716 ADAIR AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2836
Practice Address - Country:US
Practice Address - Phone:740-891-9000
Practice Address - Fax:740-891-9001
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006885207R00000X
OH34-006885207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2136709Medicaid
OHH01132Medicare UPIN
9352411Medicare PIN
OH2136709Medicaid