Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 88692 | GA |
Y | 111NI0900X | Internist | 88692 | GA |
NPI | 1003311705 |
---|---|
Provider Name | Dr. Travis Daniel Bontrager |
First Address | Tallahassee, FL 32308-5438 |
Second Address | Thomasville, GA 31792-5473 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2018 |
Last Update Date | 10/06/2021 |