Provider Demographics
NPI:1700116233
Name:BONIKOWSKE, GREGORY L (DC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:BONIKOWSKE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 N MAYFAIR RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1506
Mailing Address - Country:US
Mailing Address - Phone:414-837-4468
Mailing Address - Fax:414-837-4212
Practice Address - Street 1:2323 N MAYFAIR RD
Practice Address - Street 2:SUITE 104
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1506
Practice Address - Country:US
Practice Address - Phone:414-837-4468
Practice Address - Fax:414-837-4212
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4606-012111N00000X
MN5306111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4606-012OtherWI DEPARTMENT OF REGULATION AND LICENSING