Provider Demographics
NPI:1649264359
Name:BONHAM, ROBERT ELLIS (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ELLIS
Last Name:BONHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4104 JUNIUS ST.
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246
Mailing Address - Country:US
Mailing Address - Phone:214-742-2194
Mailing Address - Fax:214-827-0162
Practice Address - Street 1:4104 JUNIUS ST.
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246
Practice Address - Country:US
Practice Address - Phone:214-742-2194
Practice Address - Fax:214-827-0162
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD3155207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC13591Medicare UPIN
00P043Medicare ID - Type Unspecified