Healthcare Provider Details

I. General information

NPI: 1821093592
Provider Name (Legal Business Name): HERBERT L BONKOVSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
WINSTON SALEM NC
27157-0001
US

IV. Provider business mailing address

2214 CUMBERLAND AVE
CHARLOTTE NC
28203-6009
US

V. Phone/Fax

Practice location:
  • Phone: 336-713-7306
  • Fax:
Mailing address:
  • Phone: 704-307-4956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number037512
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2008-00082
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: