Provider Demographics
NPI:1063110401
Name:POEPPELMAN, BONNIE JO
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:JO
Last Name:POEPPELMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-9080
Mailing Address - Country:US
Mailing Address - Phone:937-498-4225
Mailing Address - Fax:
Practice Address - Street 1:2400 MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-9080
Practice Address - Country:US
Practice Address - Phone:937-498-4225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSC13847156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician