Provider Demographics
NPI:1467439133
Name:BOHANNON, WILLIAM B (DO)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:B
Last Name:BOHANNON
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1497 LAFAYETTE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-2552
Mailing Address - Country:US
Mailing Address - Phone:706-803-8190
Mailing Address - Fax:
Practice Address - Street 1:1497 LAFAYETTE PKWY
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-2552
Practice Address - Country:US
Practice Address - Phone:706-803-8190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD0818207Q00000X
GA92783207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051527910Medicaid
AL051527910OtherBCBS
I20453Medicare UPIN
AL051527910OtherBCBS