Basic Information
| Provider Information | |||||||||
| NPI: | 1760485080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONGU | ||||||||
| FirstName: | RAM MOHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40908 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283090908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106096448 | ||||||||
| FaxNumber: | 9106097040 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 ROBESON ST | ||||||||
| Address2: | STE 202 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283015520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106091630 | ||||||||
| FaxNumber: | 9106091636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 11/18/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 200300007 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8913352 | 05 | NC | MEDICAID |