Provider Demographics
NPI:1992963763
Name:CHARLES SMOTHERS, BONNIE ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:ELIZABETH
Last Name:CHARLES SMOTHERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 N HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-4913
Mailing Address - Country:US
Mailing Address - Phone:316-685-1381
Mailing Address - Fax:
Practice Address - Street 1:855 N HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4913
Practice Address - Country:US
Practice Address - Phone:316-685-1381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200739460AMedicaid
KS200739460AMedicaid