Provider Demographics
NPI:1477728970
Name:NILAH NICOLE BONHAM OD PC
Entity Type:Organization
Organization Name:NILAH NICOLE BONHAM OD PC
Other - Org Name:EYECARE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NILAH
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:BONHAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-443-0060
Mailing Address - Street 1:325 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-2542
Mailing Address - Country:US
Mailing Address - Phone:812-443-0060
Mailing Address - Fax:
Practice Address - Street 1:325 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-2542
Practice Address - Country:US
Practice Address - Phone:812-443-0060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN6024820001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6024820001OtherMEDICARE PTAN
V06605Medicare UPIN