Provider Demographics
NPI:1578525341
Name:BONHAM, CRAIG A (OD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:A
Last Name:BONHAM
Suffix:
Gender:M
Credentials:OD
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 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-471-2375
Mailing Address - Fax:260-484-3367
Practice Address - Street 1:1240 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5828
Practice Address - Country:US
Practice Address - Phone:260-471-2375
Practice Address - Fax:260-484-3367
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003136A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200337500Medicaid
IN200337500Medicaid
IN771580MMedicare PIN
IN245520BMedicare PIN
IN669220001Medicare PIN
IN410047386Medicare PIN
IN160450JMedicare PIN
IN452570033Medicare PIN
U85835Medicare UPIN
INP00612810Medicare PIN