Provider Demographics
NPI:1568436426
Name:FITLEBERG, BONNIE (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:
Last Name:FITLEBERG
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 1:610 SOLAREX CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-8624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3430 WORTHINGTON BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21704-7017
Practice Address - Country:US
Practice Address - Phone:240-215-6900
Practice Address - Fax:240-436-6300
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0065201207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD926580509Medicaid
MD926580505Medicaid
MD926580509Medicaid
MDCD8143Medicare PIN
NJH50970Medicare UPIN