Provider Demographics
NPI:1104137256
Name:GBEMUDU, BONTE (MD)
Entity type:Individual
Prefix:
First Name:BONTE
Middle Name:
Last Name:GBEMUDU
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 1:3033 N CENTRAL AVE STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2808
Mailing Address - Country:US
Mailing Address - Phone:877-809-5092
Mailing Address - Fax:
Practice Address - Street 1:13471 W CORNERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2713
Practice Address - Country:US
Practice Address - Phone:877-809-5092
Practice Address - Fax:623-213-8808
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ54480207Q00000X
IA40497207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ298755Medicaid