MEDICARE: PAUL V. BONETZKY DO

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	261QU0200X	Urgent Care Clinic/Center		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34001524	OTHER	OH	STATE MEDICAL LISC.
2	0004228178	OTHER	OH	AETNA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	A68388	OTHER	OH	UPIN

General Provider Information

NPI Number	:	1770705345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAUL V. BONETZKY DO

Provider Business Mailing Address
First Line	:	8200 STATE ROUTE 366
Second Line	:
City	:	RUSSELLS POINT
State	:	OH
Zip	:	43348-9670
Country	:	US
Telephone Number	:	937-843-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	8200 STATE ROUTE 366
Second Line	:
City	:	RUSSELLS POINT
State	:	OH
Zip	:	43348-9670
Country	:	US
Telephone Number	:	937-843-5000
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MR. DEAN P BONETZKY
Credential	:
Telephone Number	:	937-843-5000

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/21/2022

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