Provider Demographics
NPI:1376578450
Name:BONADIO, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BONADIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 S OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8927
Mailing Address - Country:US
Mailing Address - Phone:812-330-0864
Mailing Address - Fax:812-330-0864
Practice Address - Street 1:3700 S OAK RIDGE DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8927
Practice Address - Country:US
Practice Address - Phone:812-330-0864
Practice Address - Fax:812-330-0864
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2008-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001938A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist