Healthcare Provider Details

I. General information

NPI: 1174515696
Provider Name (Legal Business Name): CHARLES P. BONDURANT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date: 03/25/2006
Reactivation Date: 04/12/2006

III. Provider practice location address

1605 E BROADWAY SUITE 100
COLUMBIA MO
65201-8023
US

IV. Provider business mailing address

1605 E BROADWAY SUITE 100
COLUMBIA MO
65201-8023
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-4242
  • Fax: 573-815-4245
Mailing address:
  • Phone: 573-815-4242
  • Fax: 573-815-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberR8J14
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: