Provider Demographics
NPI:1184621310
Name:BONITATIBUS, GENA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:GENA
Middle Name:MARIE
Last Name:BONITATIBUS
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 1:4350 TOWNE CENTRE DR STE 1500
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3332
Mailing Address - Country:US
Mailing Address - Phone:706-421-1700
Mailing Address - Fax:
Practice Address - Street 1:4350 TOWNE CENTRE DR STE 1500
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3332
Practice Address - Country:US
Practice Address - Phone:706-421-1700
Practice Address - Fax:706-396-0618
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045041207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNI00467Medicare UPIN