Provider Demographics
NPI:1790738250
Name:BONNEVIE, GEORGE J III (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:J
Last Name:BONNEVIE
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 CENTRE ST
Mailing Address - Street 2:RADIOLOGY DEPARTMENT
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:508-941-7150
Mailing Address - Fax:508-941-6104
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3308
Practice Address - Country:US
Practice Address - Phone:508-941-7150
Practice Address - Fax:508-941-6104
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2171442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2005883Medicaid
MAA35396Medicare ID - Type Unspecified
MA2005883Medicaid