Provider Demographics
NPI:1962453027
Name:BONORIS, ATHANASIOS (MD)
Entity Type:Individual
Prefix:DR
First Name:ATHANASIOS
Middle Name:
Last Name:BONORIS
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 1:1726 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-2216
Mailing Address - Country:US
Mailing Address - Phone:847-824-4873
Mailing Address - Fax:
Practice Address - Street 1:1726 S ELM ST
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-2216
Practice Address - Country:US
Practice Address - Phone:847-824-4873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077564174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036077564Medicaid
01607270OtherBLUE SHIELD
110132651OtherPALMETTO GBA
IL036077564Medicaid
IL382850Medicare ID - Type Unspecified