Healthcare Provider Details

I. General information

NPI: 1467439133
Provider Name (Legal Business Name): WILLIAM B BOHANNON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1497 LAFAYETTE PKWY
LAGRANGE GA
30241-2552
US

IV. Provider business mailing address

1497 LAFAYETTE PKWY
LAGRANGE GA
30241-2552
US

V. Phone/Fax

Practice location:
  • Phone: 706-803-8190
  • Fax:
Mailing address:
  • Phone: 706-803-8190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0818
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number92783
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: