Provider Demographics
NPI:1326071648
Name:BONSALL, DEAN J (MD)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:J
Last Name:BONSALL
Suffix:
Gender:M
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:PO BOX 780
Mailing Address - Street 2:1 STADIUM DRIVE
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0780
Mailing Address - Country:US
Mailing Address - Phone:304-285-7101
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-9193
Practice Address - Country:US
Practice Address - Phone:336-716-1322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.086275207W00000X
WV24355207W00000X
OH35-08-6275208000000X
NC2018-02030207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004592Medicaid
G72943Medicare UPIN
WV3810004592Medicaid