Healthcare Provider Details

I. General information

NPI: 1477748986
Provider Name (Legal Business Name): NILAH NICOLE BONHAM OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W NATIONAL AVE
BRAZIL IN
47834
US

IV. Provider business mailing address

325 W NATIONAL AVE
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 TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number18003365A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003365B
License Number StateIN

VIII. Authorized Official

Name: DR. NILAH NICOLE BONHAM
Title or Position: OPTOMETRIST
Credential: OD
Phone: 812-443-0060