Provider Demographics
NPI:1780878579
Name:BALTOSSER, BONNIE SUE
Entity type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:SUE
Last Name:BALTOSSER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1636
Mailing Address - Country:US
Mailing Address - Phone:419-636-0086
Mailing Address - Fax:
Practice Address - Street 1:415 PARKVIEW AVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1636
Practice Address - Country:US
Practice Address - Phone:419-636-0086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 033077302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization