Provider Demographics
NPI:1487658761
Name:BONACUM, MICHAEL G (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:BONACUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1263 HOSPITAL DR NW
Mailing Address - Street 2:SUITE 250
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-2172
Mailing Address - Country:US
Mailing Address - Phone:812-738-8136
Mailing Address - Fax:812-738-3155
Practice Address - Street 1:1263 HOSPITAL DR NW
Practice Address - Street 2:SUITE 250
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-2172
Practice Address - Country:US
Practice Address - Phone:812-738-8136
Practice Address - Fax:812-738-3155
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2022-07-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN02001396207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200008150Medicaid
IN200008150Medicaid
INB41630Medicare UPIN