Healthcare Provider Details

I. General information

NPI: 1811961600
Provider Name (Legal Business Name): MARK W BONNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1157 FORSYTH ST
MACON GA
31201
US

IV. Provider business mailing address

2400 BELLEVUE RD STE 21A
DUBLIN GA
31021-2890
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-8581
  • Fax: 478-328-0438
Mailing address:
  • Phone: 478-275-7202
  • Fax: 478-274-8418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number057047
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number057047
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number057047
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number057047
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number057047
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number057047
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number057047
License Number StateGA
# 8
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number057047
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: