Provider Demographics
NPI:1568575041
Name:REDDICK, BONZO K (MD)
Entity Type:Individual
Prefix:DR
First Name:BONZO
Middle Name:K
Last Name:REDDICK
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 1:1107 E 66TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-5701
Mailing Address - Country:US
Mailing Address - Phone:912-350-8404
Mailing Address - Fax:912-350-8067
Practice Address - Street 1:1107 E 66TH ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404
Practice Address - Country:US
Practice Address - Phone:912-350-8404
Practice Address - Fax:912-350-8067
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401669207Q00000X
GA072097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003147505AMedicaid
GAP01337521OtherRAILROAD MEDICARE
SCGA1657Medicaid
NC5901642Medicaid
NC2043636OtherMEDICARE
NC5901642Medicaid
GA003147505AMedicaid