Provider Demographics
NPI:1679510408
Name:JOSEPH E BONELLI, MD
Entity Type:Organization
Organization Name:JOSEPH E BONELLI, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:E
Authorized Official - Last Name:BONELLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-522-0122
Mailing Address - Street 1:PO BOX 7643
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0643
Mailing Address - Country:US
Mailing Address - Phone:970-663-2742
Mailing Address - Fax:970-667-0847
Practice Address - Street 1:615 FAIRHURST ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-4564
Practice Address - Country:US
Practice Address - Phone:970-522-0122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27063174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO220009129OtherRAILROAD MEDICARE
CO01276039Medicaid
COM31406OtherPINNACOL
CO06D0516879OtherCLIA
COC11511Medicare PIN