Healthcare Provider Details

I. General information

NPI: 1669829776
Provider Name (Legal Business Name): BONNIE SMITH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2355 S WESTERN AVE
CHICAGO IL
60608-3837
US

IV. Provider business mailing address

966 W 21ST ST
CHICAGO IL
60608-4511
US

V. Phone/Fax

Practice location:
  • Phone: 732-541-4007
  • Fax: 312-829-6375
Mailing address:
  • Phone: 773-254-1400
  • Fax: 312-829-6375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036150551
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: