Individual
BRIAN R BONFARDIN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2306 KNOB CREEK RD STE 104, JOHNSON CITY, TN 37604-2366
(423) 794-7490
(423) 735-0289
Mailing address
2306 KNOB CREEK RD STE 104, JOHNSON CITY, TN 37604-2366
(423) 794-7490
(423) 735-0289
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
22059
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
22059
MEDICAL LICENSE
TN
05
—
BB2996140
—
TN
Enumeration date
11/07/2005
Last updated
03/25/2025
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