MEDICARE: MARK W BONNER MD

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	057047	GA
2	207NS0135X	Procedural Dermatology Physician	057047	GA
3	207ND0900X	Dermatopathology Physician	057047	GA
4	207NI0002X	Clinical & Laboratory Dermatological Immunology Physician	057047	GA
5	207NP0225X	Pediatric Dermatology Physician	057047	GA
6	183500000X	Pharmacist	057047	GA
7	208D00000X	General Practice Physician	057047	GA
8	207N00000X	Dermatology Physician	057047	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DC4061	OTHER	GA	RAILROAD MEDICARE
3	P00258031	OTHER	GA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811961600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK W BONNER MD

Provider Business Mailing Address
First Line	:	2400 BELLEVUE RD STE 21A
Second Line	:
City	:	DUBLIN
State	:	GA
Zip	:	31021-2890
Country	:	US
Telephone Number	:	478-275-7202
Fax Number	:	478-274-8418

Provider Business Practice Location Address
First Line	:	1157 FORSYTH ST
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31201
Country	:	US
Telephone Number	:	478-745-8581
Fax Number	:	478-328-0438

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

Provider Enumeration Date	:	02/16/2006
Last Update Date	:	05/03/2024

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Directions to “ MARK W BONNER MD” Practice Location

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