Provider Demographics
NPI:1568599470
Name:RODIN, BONNIE (DT)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:RODIN
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9053 LINCOLNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60203-1824
Mailing Address - Country:US
Mailing Address - Phone:847-508-0275
Mailing Address - Fax:847-492-7962
Practice Address - Street 1:9053 LINCOLNWOOD DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60203-1824
Practice Address - Country:US
Practice Address - Phone:847-508-0275
Practice Address - Fax:847-492-7962
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBR76270301P174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist