Provider Demographics
NPI:1922015494
Name:WANG, BONITA M (DO)
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:M
Last Name:WANG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12745 S SAGINAW ST
Mailing Address - Street 2:806-189
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-2437
Mailing Address - Country:US
Mailing Address - Phone:810-732-1900
Mailing Address - Fax:810-732-1925
Practice Address - Street 1:G-1425 S. GRAHAM ROAD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532
Practice Address - Country:US
Practice Address - Phone:810-732-1900
Practice Address - Fax:810-732-1925
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011000207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4153160Medicaid
MIF93997Medicare UPIN
MI4153160Medicaid