MEDICARE: MARIAN EDITH BONNER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	K7247	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00316215	OTHER	TX	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1306813589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAN EDITH BONNER M.D.

Provider Business Mailing Address
First Line	:	714 FM 1960 RD W
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-3408
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7600 BEECHNUT ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77074-4302
Country	:	US
Telephone Number	:	281-880-6991
Fax Number	:	713-432-0221

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	03/19/2009

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