Provider Demographics
NPI:1861580193
Name:BONGU, INDRANI (MD)
Entity type:Individual
Prefix:DR
First Name:INDRANI
Middle Name:
Last Name:BONGU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2806 HILLCREEK DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6484
Mailing Address - Country:US
Mailing Address - Phone:706-863-0200
Mailing Address - Fax:706-863-4695
Practice Address - Street 1:2806 HILLCREEK DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6484
Practice Address - Country:US
Practice Address - Phone:706-863-0200
Practice Address - Fax:706-863-4695
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049418207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00888841BMedicaid
GA52820654OtherBCBS GA PROVIDER NUMBER
SCG49418OtherSC MEDICAID
SCG49418OtherSC MEDICAID
BB7075066OtherDEA
GA16BBBTDMedicare ID - Type Unspecified