Provider Demographics
NPI:1013925387
Name:FOGGIE, GOLDWYN BONNER (MD)
Entity Type:Individual
Prefix:DR
First Name:GOLDWYN
Middle Name:BONNER
Last Name:FOGGIE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:9730 S WESTERN AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2814
Mailing Address - Country:US
Mailing Address - Phone:708-425-1907
Mailing Address - Fax:708-422-9816
Practice Address - Street 1:15620 WOOD ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-4171
Practice Address - Country:US
Practice Address - Phone:708-333-3030
Practice Address - Fax:708-333-6060
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2023-08-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036094353207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094353Medicaid
IL036094353Medicaid