Provider Demographics
NPI:1811909013
Name:BONTRAGER, CRIS H (DO)
Entity type:Individual
Prefix:
First Name:CRIS
Middle Name:H
Last Name:BONTRAGER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:AL
Mailing Address - Zip Code:36545-2714
Mailing Address - Country:US
Mailing Address - Phone:251-246-5114
Mailing Address - Fax:251-246-9553
Practice Address - Street 1:220 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:AL
Practice Address - Zip Code:36545-2459
Practice Address - Country:US
Practice Address - Phone:251-246-9021
Practice Address - Fax:251-246-1122
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO-902208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-29212OtherBLUE CROSS BLUE SHIELD
ALH34927Medicare UPIN