Healthcare Provider Details

I. General information

NPI: 1700849627
Provider Name (Legal Business Name): WALTER MORSE BONNER JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 JOHNNIE DODDS BLVD SUITE 2A
MT PLEASANT SC
29464-6129
US

IV. Provider business mailing address

890 JOHNNIE DODDS BLVD SUITE 2A
MT PLEASANT SC
29464-6129
US

V. Phone/Fax

Practice location:
  • Phone: 843-881-9971
  • Fax: 843-881-9973
Mailing address:
  • Phone: 843-881-9971
  • Fax: 843-881-9973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number3839
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: