Basic Information
| Provider Information | |||||||||
| NPI: | 1154884799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONZO | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 302 N HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GIRARD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667432000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6207248291 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1011 N HIGHWAY 69 | ||||||||
| Address2: | |||||||||
| City: | FRONTENAC | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667638100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202351377 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2019 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04-44000 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.