MEDICARE: DR. JIMMY DARRELL BONNER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	C4914	AR
2	207Q00000X	Family Medicine Physician	C4914	AR

General Provider Information

NPI Number	:	1700845971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JIMMY DARRELL BONNER MD

Provider Business Mailing Address
First Line	:	630 W COURT ST
Second Line	:
City	:	PARAGOULD
State	:	AR
Zip	:	72450-4247
Country	:	US
Telephone Number	:	870-236-8561
Fax Number	:	870-236-9428

Provider Business Practice Location Address
First Line	:	630 W COURT ST
Second Line	:
City	:	PARAGOULD
State	:	AR
Zip	:	72450-4247
Country	:	US
Telephone Number	:	870-236-8561
Fax Number	:	870-236-9428

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	07/16/2007

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