Provider Demographics
NPI:1972519916
Name:GREEN, BONNIE GRAHAM (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:GRAHAM
Last Name:GREEN
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 1:142 S RICE ST
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-3722
Mailing Address - Country:US
Mailing Address - Phone:828-883-5550
Mailing Address - Fax:
Practice Address - Street 1:147 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-4617
Practice Address - Country:US
Practice Address - Phone:828-884-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201402140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL42822Medicare ID - Type Unspecified
FL253454100Medicaid
G63384Medicare UPIN