Provider Demographics
NPI:1528083284
Name:BONHAM, CLARK ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:ANDREW
Last Name:BONHAM
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 1:2401 GILLHAM RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:816-701-5200
Mailing Address - Fax:816-302-9939
Practice Address - Street 1:2401 GILLHAM RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-4619
Practice Address - Country:US
Practice Address - Phone:816-701-5200
Practice Address - Fax:816-302-9939
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50750208600000X
MO2025013416208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C507500Medicaid
CAF80313Medicare UPIN
CA00C507500Medicaid
CABE052ZMedicare PIN