Provider Demographics
NPI:1376129411
Name:BONNERUP, SPENCER (MD)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:
Last Name:BONNERUP
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 1:520 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 S 7TH ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1038
Practice Address - Country:US
Practice Address - Phone:812-885-8520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2022-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11021682A207R00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program