Provider Demographics
NPI:1558920926
Name:BONNEVILLE MED PC
Entity Type:Organization
Organization Name:BONNEVILLE MED PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SMITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SADIQ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-389-1563
Mailing Address - Street 1:1685 STONE HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-1069
Mailing Address - Country:US
Mailing Address - Phone:801-389-1563
Mailing Address - Fax:
Practice Address - Street 1:5880 S HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-9447
Practice Address - Country:US
Practice Address - Phone:801-389-1563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty