Provider Demographics
NPI:1881072643
Name:BOHANNON, DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:BOHANNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 FAIRVIEW LN STE B
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4828
Mailing Address - Country:US
Mailing Address - Phone:209-536-5100
Mailing Address - Fax:209-588-0253
Practice Address - Street 1:193 FAIRVIEW LN STE B
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4828
Practice Address - Country:US
Practice Address - Phone:209-536-5100
Practice Address - Fax:209-588-0253
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A167612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty