Provider Demographics
NPI:1407857501
Name:BONNER, MACK STUART JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MACK
Middle Name:STUART
Last Name:BONNER
Suffix:JR
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 1:590 S TRADE ST
Mailing Address - Street 2:
Mailing Address - City:TRYON
Mailing Address - State:NC
Mailing Address - Zip Code:28782-3714
Mailing Address - Country:US
Mailing Address - Phone:828-859-0420
Mailing Address - Fax:828-859-0422
Practice Address - Street 1:590 S TRADE ST
Practice Address - Street 2:
Practice Address - City:TRYON
Practice Address - State:NC
Practice Address - Zip Code:28782-3714
Practice Address - Country:US
Practice Address - Phone:828-859-0420
Practice Address - Fax:828-859-0422
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27125208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC828788112Medicare ID - Type Unspecified
NC2330350Medicare ID - Type Unspecified
NC2003715Medicare ID - Type Unspecified
C82878Medicare UPIN