Provider Demographics
NPI:1306907001
Name:ELLENOFF, BONNIE P (DO)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:P
Last Name:ELLENOFF
Suffix:
Gender:F
Credentials:DO
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Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:404-370-0428
Practice Address - Street 1:3640 TRAMORE POINTE PKWY
Practice Address - Street 2:KAISER PERMANENTE WEST COBB MEDICAL CENTER
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6825
Practice Address - Country:US
Practice Address - Phone:770-439-4700
Practice Address - Fax:404-370-0428
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2022-01-13
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Provider Licenses
StateLicense IDTaxonomies
GA051644207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0009593950Medicaid
GAH64188Medicare UPIN
GA202I089279Medicare PIN
GA08CBBKSMedicare PIN