Provider Demographics
NPI:1801870639
Name:BOHNKE, KATHLEEN D (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:D
Last Name:BOHNKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11123 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 106
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-672-6550
Practice Address - Fax:260-672-6559
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049000A207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00002092719 02OtherUNITED HEALTHCARE
IN3937240024OtherMEDICARE DMEPOS
7762243OtherAETNA
IN200342340Medicaid
IN12182OtherPHYSICIANS HEALTH PLAN
IN3937240021OtherMEDICARE DMEPOS
IN000000200308OtherANTHEM
7762243OtherAETNA
00002092719 02OtherUNITED HEALTHCARE
IN3937240021OtherMEDICARE DMEPOS
IN070830FMedicare PIN