Provider Demographics
NPI:1063544674
Name:ROGER D. BONHAM M.D., P.C.
Entity type:Organization
Organization Name:ROGER D. BONHAM M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNDIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-449-3846
Mailing Address - Street 1:500 N KEENE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8105
Mailing Address - Country:US
Mailing Address - Phone:573-449-3846
Mailing Address - Fax:573-449-3846
Practice Address - Street 1:500 N KEENE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8105
Practice Address - Country:US
Practice Address - Phone:573-449-3846
Practice Address - Fax:573-449-3706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6F35207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202256202Medicaid
MODH1046OtherRAILROAD MEDICARE
MOB18393Medicare UPIN
MO000015690Medicare PIN