Provider Demographics
NPI:1679516652
Name:BONTREGER, JENNIFER MARIE (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:BONTREGER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:HEIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2014 JUSTIN RD
Mailing Address - Street 2:STE 104
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-7182
Mailing Address - Country:US
Mailing Address - Phone:469-645-0200
Mailing Address - Fax:469-637-0000
Practice Address - Street 1:2014 JUSTIN RD
Practice Address - Street 2:SUITE 104
Practice Address - City:HIGHLAND VILLAGE
Practice Address - State:TX
Practice Address - Zip Code:75077-7161
Practice Address - Country:US
Practice Address - Phone:469-645-0200
Practice Address - Fax:469-637-0000
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4954207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142996Medicare Oscar/Certification