Healthcare Provider Details

I. General information

NPI: 1093015844
Provider Name (Legal Business Name): MACK BONNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

OLD RTE 75 FEDERAL MEDICAL CENTER,
BUTNER NC
27509-4500
US

IV. Provider business mailing address

PO BOX 1500
BUTNER NC
27509-4500
US

V. Phone/Fax

Practice location:
  • Phone: 919-575-3900
  • Fax:
Mailing address:
  • Phone: 919-575-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101231922
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: