Provider Demographics
NPI:1720183130
Name:BONNESS, MICHELLE R (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:R
Last Name:BONNESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20320 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-3737
Mailing Address - Country:US
Mailing Address - Phone:262-782-7021
Mailing Address - Fax:262-782-8738
Practice Address - Street 1:20320 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-3737
Practice Address - Country:US
Practice Address - Phone:262-782-7021
Practice Address - Fax:262-782-8738
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38739-020208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32428700Medicaid
G44064Medicare UPIN
WI32428700Medicaid