Healthcare Provider Details

I. General information

NPI: 1457287401
Provider Name (Legal Business Name): MAXWELL BONGHI O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4389 BEAUFORT RD, HAVELOCK, NC
FPO AA
28532
US

IV. Provider business mailing address

213 LYNDEN LN
NEW BERN NC
28560-8556
US

V. Phone/Fax

Practice location:
  • Phone: 252-466-0921
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14289376-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: