Healthcare Provider Details

I. General information

NPI: 1336306547
Provider Name (Legal Business Name): JOHNNY LEE BONNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E SOUTH BLVD
MONTGOMERY AL
36116-2409
US

IV. Provider business mailing address

4310 BRONTE LN
DOUGLASVILLE GA
30135-4981
US

V. Phone/Fax

Practice location:
  • Phone: 334-288-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number30062
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number67277
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number30062
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number67277
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: