Provider Demographics
NPI:1568403871
Name:BONACUM, JULIA T (MD)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:T
Last Name:BONACUM
Suffix:
Gender:F
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 64075
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4075
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 SAINT PAUL PL
Practice Address - Street 2:11TH FLOOR
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2102
Practice Address - Country:US
Practice Address - Phone:410-332-9573
Practice Address - Fax:410-238-5598
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0050236207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS185 / 0001OtherBLUECHOICE
MD024700600Medicaid
MDKX 46 ST / 547804-04OtherBC / BS OF MD
MD024700600Medicaid
G43499Medicare UPIN