Healthcare Provider Details

I. General information

NPI: 1215222765
Provider Name (Legal Business Name): HOUSTON GORDON BONNYMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 SAINT CHARLES AVE FL 4
NEW ORLEANS LA
70115-4637
US

IV. Provider business mailing address

3600 PRYTANIA ST STE 35
NEW ORLEANS LA
70115-3678
US

V. Phone/Fax

Practice location:
  • Phone: 504-897-8412
  • Fax: 504-249-5311
Mailing address:
  • Phone: 504-897-8412
  • Fax: 504-249-5311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086H0002X
TaxonomyHospice and Palliative Medicine (Surgery) Physician
License Number300355
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number300355
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: