Individual
JACK W. BONNER III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
701 GROVE RD, GREENVILLE, SC 29605-5611
(864) 455-8431
Mailing address
7 INDEPENDENCE PT, SUITE 140, GREENVILLE, SC 29615-4566
(864) 797-6044
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
17455
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
174555
—
SC
Enumeration date
05/10/2006
Last updated
12/28/2009
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