Provider Demographics
NPI:1053351817
Name:JOHN L BONNER EYE CLINIC LTD
Entity type:Organization
Organization Name:JOHN L BONNER EYE CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-326-3343
Mailing Address - Street 1:1542 GOLF COURSE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-9603
Mailing Address - Country:US
Mailing Address - Phone:218-326-3433
Mailing Address - Fax:218-326-3435
Practice Address - Street 1:1542 GOLF COURSE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-9603
Practice Address - Country:US
Practice Address - Phone:218-326-3433
Practice Address - Fax:218-326-3435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN432152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0186560001OtherDMERC