Basic Information
| Provider Information | |||||||||
| NPI: | 1013013226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONNIN | ||||||||
| FirstName: | IRVIN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 991 W HUDSON BLVD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280526430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048535000 | ||||||||
| FaxNumber: | 7048626194 | ||||||||
| Practice Location | |||||||||
| Address1: | 991 W HUDSON BLVD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280526430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048535000 | ||||||||
| FaxNumber: | 7048626194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 02/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 19045 | NC | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 19045 | 01 | NC | LISCENCE # | OTHER | 8916437 | 05 | NC | MEDICAID |