Provider Demographics
NPI:1568427375
Name:DAVIDSON, BONNIE L (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:L
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:L
Other - Last Name:SUTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:407 S MAIN ST
Mailing Address - Street 2:STE 400
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-4000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 S MAIN ST STE 400
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665
Practice Address - Country:US
Practice Address - Phone:608-637-3174
Practice Address - Fax:608-638-5038
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49048207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine