Provider Demographics
NPI:1346204534
Name:BONNEY, CHARLES STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:STEPHEN
Last Name:BONNEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C STEPHEN
Other - Middle Name:
Other - Last Name:BONNEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:503 N MAIN ST
Mailing Address - Street 2:SUITE 640
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3130
Mailing Address - Country:US
Mailing Address - Phone:719-542-6000
Mailing Address - Fax:719-542-6037
Practice Address - Street 1:503 N MAIN ST
Practice Address - Street 2:SUITE 640
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3130
Practice Address - Country:US
Practice Address - Phone:719-542-6000
Practice Address - Fax:719-542-6037
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO190992084P0800X
WY2390A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01190990Medicaid
COD23546Medicare UPIN
COCH1608Medicare ID - Type Unspecified