Healthcare Provider Details

I. General information

NPI: 1336129626
Provider Name (Legal Business Name): MARK W BONNEVILLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 HART BLVD
MONTICELLO MN
55362-8575
US

IV. Provider business mailing address

12955 30TH AVE N
PLYMOUTH MN
55441-2738
US

V. Phone/Fax

Practice location:
  • Phone: 763-271-2386
  • Fax: 763-271-2890
Mailing address:
  • Phone: 763-553-1070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35582
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: