Provider Demographics
NPI:1063417632
Name:CARTER, BONNIE C (MD)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:C
Last Name:CARTER
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:PO BOX 2129
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-2129
Mailing Address - Country:US
Mailing Address - Phone:432-640-6712
Mailing Address - Fax:432-640-4788
Practice Address - Street 1:1940 E 42ND ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5840
Practice Address - Country:US
Practice Address - Phone:432-640-6712
Practice Address - Fax:432-640-4788
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2017-10-19
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-06-12
Provider Licenses
StateLicense IDTaxonomies
TXL5693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168174411Medicaid
TX168174411Medicaid
TX168174401Medicaid