Provider Demographics
NPI:1366498784
Name:BONNER, TIMOTHY CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:CHARLES
Last Name:BONNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1542 GOLF COURSE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-9603
Mailing Address - Country:US
Mailing Address - Phone:218-326-3433
Mailing Address - Fax:218-326-3435
Practice Address - Street 1:1542 GOLF COURSE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-9603
Practice Address - Country:US
Practice Address - Phone:218-326-3433
Practice Address - Fax:218-326-3435
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27813207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN225067500Medicaid
MN27813OtherSTATE LICENSE
MND48427Medicare UPIN
MN189000445Medicare ID - Type UnspecifiedGRAND RAPIDS LOCATION
MN225067500Medicaid