Provider Demographics
NPI:1821478769
Name:BONDOW, BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BONDOW
Suffix:
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 1:530 N 108TH PL STE 202
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4253
Mailing Address - Country:US
Mailing Address - Phone:414-797-3551
Mailing Address - Fax:262-244-5946
Practice Address - Street 1:530 N 108TH PL STE 202
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4253
Practice Address - Country:US
Practice Address - Phone:414-797-3551
Practice Address - Fax:262-244-5946
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI71910-20207QS0010X
KY51293207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine