Provider Demographics
NPI:1699705582
Name:BONWELL, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BONWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8702
Mailing Address - Country:US
Mailing Address - Phone:970-624-4443
Mailing Address - Fax:970-490-4175
Practice Address - Street 1:1715 N WEBER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-7532
Practice Address - Country:US
Practice Address - Phone:719-632-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45483207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92578705Medicaid
CO92578705Medicaid
C810400Medicare PIN
C809108Medicare PIN
COCOA109560Medicare PIN