Provider Demographics
NPI:1336129626
Name:BONNEVILLE, MARK W (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:W
Last Name:BONNEVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12955 30TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2738
Mailing Address - Country:US
Mailing Address - Phone:763-553-1070
Mailing Address - Fax:
Practice Address - Street 1:1013 HART BLVD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8575
Practice Address - Country:US
Practice Address - Phone:763-271-2386
Practice Address - Fax:763-271-2890
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35582207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN069268900Medicaid
MNF31800Medicare UPIN
MN080005074Medicare ID - Type Unspecified