1003878794 NPI number — EDWARD VINCENT BONYAK MD

Table of content: PAUL D HAVENSTEIN M.D. (NPI 1053330571)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003878794 NPI number — EDWARD VINCENT BONYAK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONYAK
Provider First Name:
EDWARD
Provider Middle Name:
VINCENT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003878794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2410 ATHERHOLT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNCHBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24501-2148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-200-5252
Provider Business Mailing Address Fax Number:
434-200-5252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
95 HARRIS RD # MOB1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KILMARNOCK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22482-3845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-435-7735
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  20934 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 0101048188 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 550941600 . This is a "MD MEDICAID GRP IN VA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 9332051 . This is a "WV MEDICARE GRP OLD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0086502000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08251100000 . This is a "QUALCHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2119629 . This is a "MAMSI PROFESSIONAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000486018 . This is a "WV BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9371521 . This is a "WV MEDICARE B - GROUP #" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: C00085 . This is a "VA MEDICARE B - GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000875693 . This is a "WV BLUE SHIELD - GROUP #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 211032 . This is a "ANTHEM PROFESSIONAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9332051 . This is a "WV MEDICARE B - GROUP #" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 43935 . This is a "SENTARA PROFESSIONAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00656327 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3810003817 . This is a "WV MEDICAID GROUP" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 006051120 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9371521 . This is a "WV MEDICARE GRP NEW" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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