Provider Demographics
NPI:1285828673
Name:GIFFORD, BONNIE DUPPER (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:DUPPER
Last Name:GIFFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BONNIE
Other - Middle Name:DUPPER
Other - Last Name:GOLDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:697 PANTHER CAMP CREEK ROAD
Mailing Address - Street 2:HC 67 BOX 550B
Mailing Address - City:RENICK
Mailing Address - State:WV
Mailing Address - Zip Code:24966
Mailing Address - Country:US
Mailing Address - Phone:304-497-0561
Mailing Address - Fax:
Practice Address - Street 1:697 PANTHER CAMP CREEK ROAD
Practice Address - Street 2:HC 67 BOX 550B
Practice Address - City:RENICK
Practice Address - State:WV
Practice Address - Zip Code:24966
Practice Address - Country:US
Practice Address - Phone:304-497-0561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.045288207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC02052Medicare UPIN
OH0779184Medicare PIN