Provider Demographics
NPI:1366407975
Name:BONHAM, BRIAN K (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:K
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 1:22911 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SMITHSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21783-1617
Mailing Address - Country:US
Mailing Address - Phone:301-824-3343
Mailing Address - Fax:301-824-6323
Practice Address - Street 1:22911 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SMITHSBURG
Practice Address - State:MD
Practice Address - Zip Code:21783-1617
Practice Address - Country:US
Practice Address - Phone:301-824-3343
Practice Address - Fax:301-824-6323
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MED0054451207R00000X
MDD0054451208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD507200000Medicaid
MDG94151Medicare UPIN
MD853EMedicare ID - Type Unspecified