Basic Information
| Provider Information | |||||||||
| NPI: | 1184885980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONISH | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 615 VALLEY VIEW DR STE 204 | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3092276552 | ||||||||
| FaxNumber: | 3092776553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 09/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 62964 | MN | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 036-120481 | IL | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.