Healthcare Provider Details

I. General information

NPI: 1801872338
Provider Name (Legal Business Name): MARK DOUGLAS BONNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SANTA CLARA HEALTH CENTER RR 5 BOX 446
ESPANOLA NM
87532-8908
US

IV. Provider business mailing address

RR 5 BOX 446 SANTA CLARA PUEBLO HEALTH CENTER
ESPANOLA NM
87532-8908
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-5039
  • Fax:
Mailing address:
  • Phone: 505-753-9421
  • Fax: 505-753-5039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number85-163
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number85-163
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: