Healthcare Provider Details

I. General information

NPI: 1861699969
Provider Name (Legal Business Name): LEONARDO FATOR GOUVEA BONILHA M.D. , PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 RICHLAND MEDICAL PARK DR STE 420
COLUMBIA SC
29203-8004
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-8050
  • Fax: 803-933-3005
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberLL30145
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number90870
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number30145
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number90870
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: