Provider Demographics
NPI:1164852406
Name:GOLDMAN, BONNIE S
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:S
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 CHESHAM ST
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-0691
Mailing Address - Country:US
Mailing Address - Phone:917-282-2600
Mailing Address - Fax:
Practice Address - Street 1:349 CHESHAM ST
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-0691
Practice Address - Country:US
Practice Address - Phone:917-282-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-23
Last Update Date:2013-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO119953246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant