Provider Demographics
NPI:1881636090
Name:BONEBRAKE, ALBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:J
Last Name:BONEBRAKE
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:1001 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5155
Practice Address - Country:US
Practice Address - Phone:417-875-3000
Practice Address - Fax:417-875-3450
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS35473207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
18053OtherBLUE CROSS/BLUE SHIELD
MO200249522Medicaid
18053OtherBLUE CROSS/BLUE SHIELD
MO200249522Medicaid