Provider Demographics
NPI:1326049016
Name:NOWAK, BONNIE E (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:E
Last Name:NOWAK
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 1:1106 E PROSPECT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5306
Mailing Address - Country:US
Mailing Address - Phone:970-495-7410
Mailing Address - Fax:970-495-7425
Practice Address - Street 1:1106 E PROSPECT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5306
Practice Address - Country:US
Practice Address - Phone:970-495-7410
Practice Address - Fax:970-495-7425
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5464207R00000X
CO49398207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6004840Medicaid
CO82955379Medicaid
WY133241400Medicaid
SD6004840Medicaid
SDI10710Medicare UPIN