Provider Demographics
NPI:1861505190
Name:BONTREGER, MARK ELDON (PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ELDON
Last Name:BONTREGER
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 5TH ST SE
Mailing Address - Street 2:SUITE L-13
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-4940
Mailing Address - Country:US
Mailing Address - Phone:605-882-0800
Mailing Address - Fax:605-882-0861
Practice Address - Street 1:525 5TH ST SE
Practice Address - Street 2:SUITE L-13
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-4940
Practice Address - Country:US
Practice Address - Phone:605-882-0800
Practice Address - Fax:605-882-0861
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD364103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6551792Medicaid
SDS40196Medicare PIN