Healthcare Provider Details

I. General information

NPI: 1831151216
Provider Name (Legal Business Name): JOHN D BONNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9453 DAYTON PIKE
SODDY DAISY TN
37379-4751
US

IV. Provider business mailing address

9453 DAYTON PIKE
SODDY DAISY TN
37379-4751
US

V. Phone/Fax

Practice location:
  • Phone: 423-332-8222
  • Fax: 423-332-8278
Mailing address:
  • Phone: 423-332-8222
  • Fax: 423-332-8278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD0000028919
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: