Provider Demographics
NPI:1437157724
Name:BOHM, GUILLERMO (MD)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:BOHM
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 62707
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-2707
Mailing Address - Country:US
Mailing Address - Phone:239-931-3440
Mailing Address - Fax:
Practice Address - Street 1:4061 BONITA BEACH RD STE 101
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4073
Practice Address - Country:US
Practice Address - Phone:239-301-0105
Practice Address - Fax:239-301-0110
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65227207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374091900Medicaid
FL23687AOtherBC BS
E94163Medicare UPIN
FL23687AOtherBC BS