Provider Demographics
NPI:1295718823
Name:BONNER, BRIAN K (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:BONNER
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 1:521 GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15207-1091
Mailing Address - Country:US
Mailing Address - Phone:412-422-6500
Mailing Address - Fax:412-422-4357
Practice Address - Street 1:521 GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15207-1091
Practice Address - Country:US
Practice Address - Phone:412-422-6500
Practice Address - Fax:412-422-4357
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD424481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009892050001Medicaid
PA1009892050001Medicaid
PA080357RNOMedicare ID - Type Unspecified