Basic Information
| Provider Information | |||||||||
| NPI: | 1356788616 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONEBRAKE | ||||||||
| FirstName: | TED | ||||||||
| MiddleName: | ARTHUR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 KIMBALL AVE | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413446632 | ||||||||
| FaxNumber: | 3192722107 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 KIMBALL AVE | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507025014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413446632 | ||||||||
| FaxNumber: | 3192722107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 05/28/2013 | ||||||||
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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 | 32655 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.