Provider Demographics
NPI:1811961600
Name:BONNER, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:BONNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2400 BELLEVUE RD STE 21A
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2890
Mailing Address - Country:US
Mailing Address - Phone:478-275-7202
Mailing Address - Fax:478-274-8418
Practice Address - Street 1:1157 FORSYTH ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-745-8581
Practice Address - Fax:478-328-0438
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0570471835P0018X, 207NS0135X, 207ND0900X, 207NI0002X, 207NP0225X, 183500000X, 208D00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No183500000XPharmacy Service ProvidersPharmacist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA413577315AMedicaid
GADC4061OtherRAILROAD MEDICARE
GAP00258031OtherRAILROAD MEDICARE
GAGRP6800Medicare PIN
GADC4061OtherRAILROAD MEDICARE
H20672Medicare UPIN