Healthcare Provider Details

I. General information

NPI: 1376578450
Provider Name (Legal Business Name): MARK BONADIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 05/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 S OAK RIDGE DR
BLOOMINGTON IN
47401-8927
US

IV. Provider business mailing address

3700 S OAK RIDGE DR
BLOOMINGTON IN
47401-8927
US

V. Phone/Fax

Practice location:
  • Phone: 812-330-0864
  • Fax: 812-330-0864
Mailing address:
  • Phone: 812-330-0864
  • Fax: 812-330-0864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31001938A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: