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General NPI Number Information
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NPI Number | 1184621310
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Entity Type | Individual
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Provider Name | GENA MARIE BONITATIBUS M.D.
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Gender | Female
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Dates
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Enumeration Date | 07/01/2005
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Last Update Date | 03/05/2024
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Provider Practice Location Address
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Address Line | 4350 TOWNE CENTRE DR STE 1500
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City | EVANS
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State | GA
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Zip | 30809-3332
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Country | US
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Telephone | 706-421-1700
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Fax | 706-396-0618
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Provider Business Mailing Address
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Address Line | 4350 TOWNE CENTRE DR STE 1500
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City | EVANS
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State | GA
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Zip | 30809-3332
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Country | US
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Telephone | 706-421-1700
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 045041
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License Number State | GA
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