Provider Demographics
NPI:1356322515
Name:BONFARDIN, BRIAN R (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:BONFARDIN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 KNOB CREEK RD STE 104
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2366
Mailing Address - Country:US
Mailing Address - Phone:423-794-7490
Mailing Address - Fax:423-735-0289
Practice Address - Street 1:2306 KNOB CREEK RD STE 104
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2366
Practice Address - Country:US
Practice Address - Phone:423-794-7490
Practice Address - Fax:423-735-0289
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN220592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNBB2996140Medicaid
TN22059OtherMEDICAL LICENSE