Provider Demographics
NPI:1366514549
Name:BONHEIM, NELSON A (MD)
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:A
Last Name:BONHEIM
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 1:500 W PUTNAM AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-6086
Mailing Address - Country:US
Mailing Address - Phone:203-863-2900
Mailing Address - Fax:203-863-2901
Practice Address - Street 1:500 W PUTNAM AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-6086
Practice Address - Country:US
Practice Address - Phone:203-863-2900
Practice Address - Fax:203-863-2901
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017080207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT017080OtherCOMMERCIAL
CT1170802Medicaid
CTB38426Medicare UPIN
CT1170802Medicaid