Basic Information
| Provider Information | |||||||||
| NPI: | 1013993039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONNETTE | ||||||||
| FirstName: | RICK | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W WORLEY ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652032037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732142314 | ||||||||
| FaxNumber: | 5738142784 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652811037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6603886446 | ||||||||
| FaxNumber: | 6603886870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R6J76 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31906016 | 01 | MO | BCBS | OTHER | 1013993039 | 05 | MO | MEDICAID |