Provider Demographics
NPI:1316904121
Name:ROBERTS, BONNI (DO)
Entity type:Individual
Prefix:
First Name:BONNI
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21922-0190
Mailing Address - Country:US
Mailing Address - Phone:410-398-4679
Mailing Address - Fax:410-620-3686
Practice Address - Street 1:361 FAIR HILL DR
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-2512
Practice Address - Country:US
Practice Address - Phone:410-620-7260
Practice Address - Fax:410-620-7262
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0062851207Q00000X
DEC2-0007295207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408570100Medicaid
P00266351OtherMEDICARE RAILROAD
MD199NMedicare PIN
P00266351OtherMEDICARE RAILROAD
MDI31842Medicare UPIN