Healthcare Provider Details

I. General information

NPI: 1326031667
Provider Name (Legal Business Name): BEDFORD W. BONTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N STATE OF FRANKLIN RD 1ST FLOOR
JOHNSON CITY TN
37604-6035
US

IV. Provider business mailing address

PO BOX 699
MOUNTAIN HOME TN
37684-0699
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-6671
  • Fax: 423-431-2916
Mailing address:
  • Phone: 423-431-6671
  • Fax: 423-431-2916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD24551
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: