Healthcare Provider Details

I. General information

NPI: 1275635534
Provider Name (Legal Business Name): NILAH NICOLE BONHAM O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W NATIONAL AVENUE
BRAZIL IN
47834
US

IV. Provider business mailing address

325 W NATIONAL AVENUE
BRAZIL IN
47834
US

V. Phone/Fax

Practice location:
  • Phone: 812-443-0060
  • Fax: 812-446-5061
Mailing address:
  • Phone: 812-443-0060
  • Fax: 812-446-5061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003365A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: