Provider Demographics
NPI:1740381276
Name:BOHANNON, TODD (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:BOHANNON
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 1:1703 JOHNSON BLVD
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2264
Mailing Address - Country:US
Mailing Address - Phone:270-761-1999
Mailing Address - Fax:
Practice Address - Street 1:503 GEORGE MCCLAIN DR
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1331
Practice Address - Country:US
Practice Address - Phone:270-527-8144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33599207P00000X, 207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64005317Medicaid
KY000000056871OtherBCBS
KY1799501Medicare ID - Type Unspecified
KY0935602Medicare PIN
KY64005317Medicaid