Provider Demographics
NPI:1073764403
Name:FONJI, BERTRAND BEZANCHONG TEH (MD)
Entity Type:Individual
Prefix:
First Name:BERTRAND
Middle Name:BEZANCHONG TEH
Last Name:FONJI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:11001 EXECUTIVE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4316
Mailing Address - Country:US
Mailing Address - Phone:501-329-1415
Mailing Address - Fax:501-329-2589
Practice Address - Street 1:650 UNITED DR STE 240
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-7004
Practice Address - Country:US
Practice Address - Phone:501-329-1415
Practice Address - Fax:501-329-2589
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE-11895208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008921000Medicaid
FLHH231ZMedicare PIN