Provider Demographics
NPI:1326031667
Name:BONTA, BEDFORD W (MD)
Entity Type:Individual
Prefix:
First Name:BEDFORD
Middle Name:W
Last Name:BONTA
Suffix:
Gender:M
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-431-6671
Mailing Address - Fax:423-431-2916
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-431-6671
Practice Address - Fax:423-431-2916
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD245512080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3079901Medicare ID - Type Unspecified