Provider Demographics
NPI:1801872338
Name:BONNELL, MARK DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DOUGLAS
Last Name:BONNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:RR 5 BOX 446
Mailing Address - Street 2:SANTA CLARA PUEBLO HEALTH CENTER
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-8908
Mailing Address - Country:US
Mailing Address - Phone:505-753-9421
Mailing Address - Fax:505-753-5039
Practice Address - Street 1:SANTA CLARA HEALTH CENTER
Practice Address - Street 2:RR 5 BOX 446
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-8908
Practice Address - Country:US
Practice Address - Phone:505-753-5039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM85-163207QG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA02516Medicare UPIN