Provider Demographics
NPI:1063717304
Name:FARMVILLE INTERNAL MEDICINE, PC
Entity type:Organization
Organization Name:FARMVILLE INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VARA
Authorized Official - Middle Name:P
Authorized Official - Last Name:BONAGIRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-392-9000
Mailing Address - Street 1:PO BOX R
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-0289
Mailing Address - Country:US
Mailing Address - Phone:434-392-9000
Mailing Address - Fax:434-392-9215
Practice Address - Street 1:1400 MILNWOOD RD
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2633
Practice Address - Country:US
Practice Address - Phone:434-392-9000
Practice Address - Fax:434-392-9215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054184207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5865514Medicaid
VA110008239Medicare PIN
VAG30824Medicare UPIN