Provider Demographics
NPI:1699725044
Name:BROWN, BONNIE SUSANNE (MD)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:SUSANNE
Last Name:BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2309
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-2309
Mailing Address - Country:US
Mailing Address - Phone:270-706-1023
Mailing Address - Fax:270-706-1167
Practice Address - Street 1:11969 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:KY
Practice Address - Zip Code:42776-9739
Practice Address - Country:US
Practice Address - Phone:270-369-9706
Practice Address - Fax:270-369-9263
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY080172384OtherMCR RAILROAD
KY2437780000OtherPASSPORT ADVANTAGE MCR
KY1133127OtherPSPT
KY000000202961OtherBC/BS PIN
KY64337827Medicaid
KY000000202961OtherBC/BS PIN
KY0745402Medicare PIN