Provider Demographics
NPI:1346567146
Name:BONVILLAIN, JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:BONVILLAIN
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 1:19343 SUNSHINE AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8834
Mailing Address - Country:US
Mailing Address - Phone:985-892-5117
Mailing Address - Fax:985-892-5128
Practice Address - Street 1:19343 SUNSHINE AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8834
Practice Address - Country:US
Practice Address - Phone:985-892-5117
Practice Address - Fax:985-892-5128
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303155207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2102885Medicaid
LA533247YMWVMedicare PIN