Provider Demographics
NPI:1942363965
Name:BOHANNON, CARL DOUGLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:DOUGLAS
Last Name:BOHANNON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 E CENTRAL
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-2222
Mailing Address - Country:US
Mailing Address - Phone:316-321-1667
Mailing Address - Fax:316-321-1762
Practice Address - Street 1:1425 E CENTRAL
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2222
Practice Address - Country:US
Practice Address - Phone:316-321-1667
Practice Address - Fax:316-321-1762
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0103679111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS014222Medicare ID - Type Unspecified