Provider Demographics
NPI:1407855778
Name:BONHAM, ROGER D (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
Last Name:BONHAM
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 1:500 N KEENE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8105
Mailing Address - Country:US
Mailing Address - Phone:573-449-3846
Mailing Address - Fax:573-449-3706
Practice Address - Street 1:500 N KEENE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8104
Practice Address - Country:US
Practice Address - Phone:573-449-3846
Practice Address - Fax:573-449-3706
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR6F35207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO180012949OtherRAILROAD MEDICARE
MO202256202Medicaid
MO024825690Medicare PIN
MO202256202Medicaid