Provider Demographics
NPI:1710983283
Name:BONNER, CHARLES HENDERSON SR (MD, MS, CRP)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HENDERSON
Last Name:BONNER
Suffix:SR
Gender:M
Credentials:MD, MS, CRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5922 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-2231
Mailing Address - Country:US
Mailing Address - Phone:804-282-6953
Mailing Address - Fax:804-282-8215
Practice Address - Street 1:5922 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-2231
Practice Address - Country:US
Practice Address - Phone:804-282-6953
Practice Address - Fax:804-282-8215
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0715002791208100000X
VA0101032689208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
250000023Medicare ID - Type Unspecified
B06079Medicare UPIN