Provider Demographics
NPI:1497268437
Name:BONK, TOM
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:BONK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:DE
Mailing Address - Zip Code:19730-0639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:167 TAYLORS BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:DE
Practice Address - Zip Code:19730
Practice Address - Country:US
Practice Address - Phone:302-690-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
No171W00000XOther Service ProvidersContractor