Healthcare Provider Details

I. General information

NPI: 1265720106
Provider Name (Legal Business Name): BONNI NICOLE HEITHOLD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DRIVE
COLUMBIA MO
65212
US

IV. Provider business mailing address

1 HOSPITAL DRIVE
COLUMBIA MO
65212
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-4438
  • Fax: 573-884-9992
Mailing address:
  • Phone: 573-882-4438
  • Fax: 573-884-9992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2011017906
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: