Provider Demographics
NPI:1235105818
Name:BONTRAGER, DANIEL E (DC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
Last Name:BONTRAGER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4439 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32448
Mailing Address - Country:US
Mailing Address - Phone:850-526-4830
Mailing Address - Fax:850-482-2757
Practice Address - Street 1:4439 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32448
Practice Address - Country:US
Practice Address - Phone:850-526-4830
Practice Address - Fax:850-482-2757
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0004409111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
70332Medicare ID - Type Unspecified
T85413Medicare UPIN