Provider Demographics
NPI:1609838432
Name:BONACK, TIMOTHY D (PT DOMPCC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:D
Last Name:BONACK
Suffix:
Gender:M
Credentials:PT DOMPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6189 LEHMAN DR STE 202
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-5409
Mailing Address - Country:US
Mailing Address - Phone:719-694-8342
Mailing Address - Fax:719-694-8347
Practice Address - Street 1:6189 LEHMAN DR STE 202
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5409
Practice Address - Country:US
Practice Address - Phone:719-694-8342
Practice Address - Fax:719-694-8347
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23732251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
P67783Medicare UPIN
CO469148Medicare ID - Type Unspecified