Healthcare Provider Details

I. General information

NPI: 1194724328
Provider Name (Legal Business Name): JOHN S BONEBRAKE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

707 N 36TH ST SUITE A
SAINT JOSEPH MO
64506-2968
US

IV. Provider business mailing address

707 N 36TH ST SUITE A
SAINT JOSEPH MO
64506-2968
US

V. Phone/Fax

Practice location:
  • Phone: 816-279-5683
  • Fax: 816-279-5685
Mailing address:
  • Phone: 816-279-5683
  • Fax: 816-279-5685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02478
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: