Provider Demographics
NPI:1386758761
Name:BONEBRAKE, ROBERT G (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:BONEBRAKE
Suffix:
Gender:M
Credentials:MD
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 2797
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-2797
Mailing Address - Country:US
Mailing Address - Phone:402-354-4230
Mailing Address - Fax:402-354-6171
Practice Address - Street 1:717 N 190TH PLZ
Practice Address - Street 2:SUITE 2400
Practice Address - City:ELKHORN
Practice Address - State:NE
Practice Address - Zip Code:68022-3913
Practice Address - Country:US
Practice Address - Phone:402-815-1970
Practice Address - Fax:402-815-1595
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19313207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1386758761Medicaid
NE470376604-16Medicaid
IA1386758761Medicaid