Provider Demographics
NPI:1629033519
Name:BONGERS, GREGORY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:THOMAS
Last Name:BONGERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N ROCK RD
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3705
Mailing Address - Country:US
Mailing Address - Phone:316-788-6963
Mailing Address - Fax:316-788-5373
Practice Address - Street 1:1101 N ROCK RD
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-3705
Practice Address - Country:US
Practice Address - Phone:316-788-6963
Practice Address - Fax:316-788-5373
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-26353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110501001Medicare PIN
G33019Medicare UPIN