Provider Demographics
NPI:1780645192
Name:BONANNI, MARC A (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:BONANNI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 BYRON RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-1410
Mailing Address - Country:US
Mailing Address - Phone:517-548-3100
Mailing Address - Fax:517-548-4594
Practice Address - Street 1:524 BYRON RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-1410
Practice Address - Country:US
Practice Address - Phone:517-548-3100
Practice Address - Fax:517-548-4594
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001940213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4144617Medicaid
MI4134728Medicaid
MI4858215680OtherBCBSM PIN
MI4134728Medicaid
MI0M67640004Medicare ID - Type Unspecified
MI4134728Medicaid
MI4858215680OtherBCBSM PIN
MI480F302060OtherBLUE CROSS BLUE SHIELD MI
MI0F36196007Medicare ID - Type Unspecified
MI480D710100OtherBLUE CROSS BLUE SHIELD MI