Provider Demographics
NPI:1194724328
Name:BONEBRAKE, JOHN S (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:BONEBRAKE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 N 36TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2968
Mailing Address - Country:US
Mailing Address - Phone:816-279-5683
Mailing Address - Fax:816-279-5685
Practice Address - Street 1:707 N 36TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2968
Practice Address - Country:US
Practice Address - Phone:816-279-5683
Practice Address - Fax:816-279-5685
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2023-03-07
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
MOT02478152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO311944706Medicaid
410048243OtherRR MEDICARE
108900OtherBC BS
MO200111698OtherCDS
MO200111698OtherCDS
T42521Medicare UPIN
0170970001Medicare NSC
MO311944706Medicaid