Provider Demographics
NPI:1780645192
Name:BONANNI, MARC A (DPM)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:A
Last Name:BONANNI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR IVE
Mailing Address - Street 2:J2000
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:990 W ANN ARBOR TRAIL
Practice Address - Street 2:SUITE 102
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1686
Practice Address - Country:US
Practice Address - Phone:734-572-1141
Practice Address - Fax:734-572-1142
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5901001940213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4134728Medicaid
MI4144617Medicaid
MI4858215680OtherBCBSM PIN
MI4134728Medicaid
MI0M67640004Medicare ID - Type Unspecified
MI4134728Medicaid
MI4858215680OtherBCBSM PIN
MI480F302060OtherBLUE CROSS BLUE SHIELD MI
MI0F36196007Medicare ID - Type Unspecified
MI480D710100OtherBLUE CROSS BLUE SHIELD MI