Provider Demographics
NPI:1811946320
Name:BONNER, BETHANN (MD)
Entity type:Individual
Prefix:
First Name:BETHANN
Middle Name:
Last Name:BONNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:1500 ASSOCIATES DR
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2201
Practice Address - Country:US
Practice Address - Phone:563-584-4440
Practice Address - Fax:563-584-4295
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA29141208000000X
WI25904208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0094193Medicaid
B84714Medicare UPIN