Provider Demographics
NPI:1295713154
Name:BONGARD, BONNIE F (MD)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:F
Last Name:BONGARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8401 GOLDEN VALLEY RD STE 330
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4488
Mailing Address - Country:US
Mailing Address - Phone:763-416-7629
Mailing Address - Fax:763-383-4147
Practice Address - Street 1:8501 GOLDEN VALLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4472
Practice Address - Country:US
Practice Address - Phone:763-416-7600
Practice Address - Fax:763-557-8982
Is Sole Proprietor?:No
Enumeration Date:2006-01-02
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN28108207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN867080300Medicaid
MN867080300Medicaid
MN180001000Medicare ID - Type Unspecified
MN180042081Medicare PIN