Provider Demographics
NPI:1215095096
Name:WIRFS, BONNIE LEE (MD)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:LEE
Last Name:WIRFS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 DOMANIK DRIVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404
Mailing Address - Country:US
Mailing Address - Phone:262-633-0500
Mailing Address - Fax:262-633-3045
Practice Address - Street 1:2000 DOMANIK DRIVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404
Practice Address - Country:US
Practice Address - Phone:262-633-0500
Practice Address - Fax:262-633-3045
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27907207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30779200Medicaid
27907OtherWISCONSIN STATE LICENSE #
BW0152796OtherDEA #
27907OtherWISCONSIN STATE LICENSE #
000052170Medicare ID - Type Unspecified