Provider Demographics
NPI:1992785703
Name:BONNER, ERNEST LINCOLN JR (MD)
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:LINCOLN
Last Name:BONNER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1406 PARK ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4560
Mailing Address - Country:US
Mailing Address - Phone:810-864-9600
Mailing Address - Fax:510-864-9690
Practice Address - Street 1:1406 PARK ST
Practice Address - Street 2:SUITE 400
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4560
Practice Address - Country:US
Practice Address - Phone:810-864-9600
Practice Address - Fax:510-864-9690
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30477207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A304771Medicaid
A26123Medicare UPIN
CA00A304771Medicaid