Provider Demographics
NPI:1437188869
Name:BONNER, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BONNER
Suffix:
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 1:2630 E CITIZENS DR
Mailing Address - Street 2:SUITE 13
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4797
Mailing Address - Country:US
Mailing Address - Phone:479-571-6000
Mailing Address - Fax:479-571-3344
Practice Address - Street 1:2630 E CITIZENS DR STE 13
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4797
Practice Address - Country:US
Practice Address - Phone:479-571-6000
Practice Address - Fax:479-571-3344
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-7247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR113998001Medicaid
ARP00200111OtherRR MCR
AR51916OtherAR BC/BS
AR51916B809Medicare PIN
ARP00200111OtherRR MCR
AR5AK74Medicare PIN
AR51916Medicare ID - Type Unspecified
ARD04572Medicare UPIN