Healthcare Provider Details

I. General information

NPI: 1346339561
Provider Name (Legal Business Name): BONNIE L. RENFRO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CONSITUTION AVE. NE
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

480W CENTRAL PKWY
ALTAMONTE SPRINGS FL
32714-2415
US

V. Phone/Fax

Practice location:
  • Phone: 505-559-1133
  • Fax: 505-724-8995
Mailing address:
  • Phone: 407-379-0186
  • Fax: 407-379-0511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number57121
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD2007-0642
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: