Provider Demographics
NPI:1124120902
Name:BONTEKOE, MICHAEL T (MS, PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:BONTEKOE
Suffix:
Gender:M
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:450 N ROXBURY DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4218
Mailing Address - Country:US
Mailing Address - Phone:424-394-1610
Mailing Address - Fax:424-394-1628
Practice Address - Street 1:450 N ROXBURY DR STE 400
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4218
Practice Address - Country:US
Practice Address - Phone:243-941-6104
Practice Address - Fax:424-394-1628
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16231363AM0700X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP68652Medicare UPIN