Healthcare Provider Details

I. General information

NPI: 1366409120
Provider Name (Legal Business Name): JOSE BONNIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 BARNHILL DR A128
INDIANAPOLIS IN
46202-5126
US

IV. Provider business mailing address

635 BARNHILL DR A128
INDIANAPOLIS IN
46202-5126
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-4806
  • Fax:
Mailing address:
  • Phone: 317-274-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number01036377A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: