Healthcare Provider Details

I. General information

NPI: 1861626574
Provider Name (Legal Business Name): MATTHEW J BONZELET M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2009
Last Update Date: 05/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 HIGHLANDS PLAZA DR E
SAINT LOUIS MO
63110-1350
US

IV. Provider business mailing address

1110 HIGHLANDS PLAZA DR E
SAINT LOUIS MO
63110-1350
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-3113
  • Fax:
Mailing address:
  • Phone: 314-367-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number55456-20
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2012021730
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: