Provider Demographics
NPI:1215222765
Name:BONNYMAN, HOUSTON GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:HOUSTON
Middle Name:GORDON
Last Name:BONNYMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3600 PRYTANIA ST STE 35
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-3678
Mailing Address - Country:US
Mailing Address - Phone:504-897-8412
Mailing Address - Fax:504-249-5311
Practice Address - Street 1:3700 SAINT CHARLES AVE FL 4
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70115-4637
Practice Address - Country:US
Practice Address - Phone:504-897-8412
Practice Address - Fax:504-249-5311
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA300355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2418980Medicaid
LA512518Medicare PIN