Healthcare Provider Details

I. General information

NPI: 1255399051
Provider Name (Legal Business Name): ALBERT HENRY BONNEMA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 LEITER RD
MIAMISBURG OH
45342-3598
US

IV. Provider business mailing address

2171 HUNTERS RIDGE BLVD
BEAVERCREEK OH
45434-7088
US

V. Phone/Fax

Practice location:
  • Phone: 937-384-4847
  • Fax:
Mailing address:
  • Phone: 210-722-7412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License Number35.067903
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-06-7903-B
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number35.067903
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: