Provider Demographics
NPI:1629141494
Name:MUSIAL, BONITA C (MD)
Entity Type:Individual
Prefix:DR
First Name:BONITA
Middle Name:C
Last Name:MUSIAL
Suffix:
Gender:F
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:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-0949
Mailing Address - Country:US
Mailing Address - Phone:601-587-2785
Mailing Address - Fax:601-587-7799
Practice Address - Street 1:314 MAIN ST.
Practice Address - Street 2:SUITE D
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654-0949
Practice Address - Country:US
Practice Address - Phone:601-587-2785
Practice Address - Fax:601-587-7799
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117007Medicaid
MS13704OtherMS PHYSICIAN LICENSE
MS080002419Medicare ID - Type UnspecifiedMEDICARE
MSF78712Medicare UPIN