Provider Demographics
NPI:1689836918
Name:BONAQUIST, CASEY RENEE (DO)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:RENEE
Last Name:BONAQUIST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746647
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6647
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:836 PRUDENTIAL DR STE 1006
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8337
Practice Address - Country:US
Practice Address - Phone:904-202-1795
Practice Address - Fax:904-376-3478
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS12248207Q00000X, 207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine