Basic Information
| Provider Information | |||||||||
| NPI: | 1417033739 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONNER | ||||||||
| FirstName: | EVERETT | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7373 PERKINS RD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2252469790 | ||||||||
| FaxNumber: | 2252469100 | ||||||||
| Practice Location | |||||||||
| Address1: | 7373 PERKINS RD. | ||||||||
| Address2: | BATON ROUGE CLINIC - ATTN: DEE - ADMINISTRATION | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257694044 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2006 | ||||||||
| LastUpdateDate: | 01/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 054561 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 201869 | LA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1076392 | 05 | LA | MEDICAID |