Provider Demographics
NPI:1215900865
Name:BONINE, TIMOTHY RAY (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:RAY
Last Name:BONINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MS
Other - First Name:TIMOTHY
Other - Middle Name:
Other - Last Name:BONINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1309 PONDEROSA DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-8278
Mailing Address - Country:US
Mailing Address - Phone:208-263-9545
Mailing Address - Fax:208-263-9539
Practice Address - Street 1:1309 PONDEROSA DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-8278
Practice Address - Country:US
Practice Address - Phone:208-263-9545
Practice Address - Fax:208-263-9539
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8424207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8063566200Medicaid
IDH-58611Medicare UPIN
ID8063566200Medicaid