Provider Demographics
NPI:1407881501
Name:BONNER, MICHAEL G (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:BONNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 JPM RD
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9313
Mailing Address - Country:US
Mailing Address - Phone:570-523-3937
Mailing Address - Fax:
Practice Address - Street 1:435 RIVER AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3722
Practice Address - Country:US
Practice Address - Phone:570-326-8070
Practice Address - Fax:570-326-0396
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
50099291OtherCAPITAL BLUE CROSS
2027189OtherBLUE SHIELD
PAP00943504OtherRAILROAD MEDICARE
PA1012670710001Medicaid
PA214769E3FMedicare PIN
2027189OtherBLUE SHIELD