Provider Demographics
NPI:1417037359
Name:BONNER, SVETLANA (MD)
Entity Type:Individual
Prefix:DR
First Name:SVETLANA
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SVETLANA
Other - Middle Name:
Other - Last Name:BONNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2455 NW MARSHALL ST STE 8B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2949
Mailing Address - Country:US
Mailing Address - Phone:503-221-3091
Mailing Address - Fax:503-222-0711
Practice Address - Street 1:2455 NW MARSHALL ST STE 8B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2949
Practice Address - Country:US
Practice Address - Phone:503-221-3091
Practice Address - Fax:503-222-0711
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD 159762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR243017Medicaid
ORE79225Medicare UPIN
ORR0000BJBGTMedicare ID - Type Unspecified