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General NPI Number Information
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NPI Number | 1801872338
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Entity Type | Individual
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Provider Name | MARK DOUGLAS BONNELL M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/16/2005
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Last Update Date | 11/19/2007
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Provider Practice Location Address
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Address Line | SANTA CLARA HEALTH CENTER RR 5 BOX 446
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City | ESPANOLA
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State | NM
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Zip | 87532-8908
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Country | US
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Telephone | 505-753-5039
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Fax |
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Provider Business Mailing Address
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Address Line | RR 5 BOX 446 SANTA CLARA PUEBLO HEALTH CENTER
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City | ESPANOLA
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State | NM
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Zip | 87532-8908
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Country | US
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Telephone | 505-753-9421
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Fax | 505-753-5039
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 85-163
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 85-163
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License Number State | NM
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