Provider Demographics
NPI:1508814286
Name:BONKOWSKI, COLLEEN (MD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:BONKOWSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 N LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-3837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3237 S 16TH ST
Practice Address - Street 2:RADIOLOGY DEPT. 2ND FLOOR
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4526
Practice Address - Country:US
Practice Address - Phone:414-647-5132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI445402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34237300Medicaid
WIH53026Medicare UPIN
WI001301250Medicare PIN