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General NPI Number Information
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NPI Number | 1356322515
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Entity Type | Individual
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Provider Name | BRIAN R BONFARDIN MD
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Gender | Male
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Dates
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Enumeration Date | 11/07/2005
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Last Update Date | 03/25/2025
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Provider Practice Location Address
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Address Line | 2306 KNOB CREEK RD STE 104
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City | JOHNSON CITY
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State | TN
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Zip | 37604-2366
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Country | US
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Telephone | 423-794-7490
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Fax | 423-735-0289
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Provider Business Mailing Address
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Address Line | 2306 KNOB CREEK RD STE 104
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City | JOHNSON CITY
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State | TN
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Zip | 37604-2366
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Country | US
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Telephone | 423-794-7490
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Fax | 423-735-0289
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 22059
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License Number State | TN
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