Provider Demographics
NPI:1336459866
Name:BONNER, GIOVANNI DYRE (IDMT)
Entity Type:Individual
Prefix:
First Name:GIOVANNI
Middle Name:DYRE
Last Name:BONNER
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 WESTGATE DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-7902
Mailing Address - Country:US
Mailing Address - Phone:707-685-0421
Mailing Address - Fax:
Practice Address - Street 1:990 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-7902
Practice Address - Country:US
Practice Address - Phone:707-685-0421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians