Provider Demographics
NPI:1316962194
Name:TEODORA M. BONUAN MD A MED CORP
Entity type:Organization
Organization Name:TEODORA M. BONUAN MD A MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TEODORA
Authorized Official - Middle Name:MALALUAN
Authorized Official - Last Name:BONUAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-804-1311
Mailing Address - Street 1:10230 ARTESIA BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-6763
Mailing Address - Country:US
Mailing Address - Phone:562-804-1311
Mailing Address - Fax:562-804-2263
Practice Address - Street 1:10230 ARTESIA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-6763
Practice Address - Country:US
Practice Address - Phone:562-804-1311
Practice Address - Fax:562-804-2263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A336971Medicaid
W19644Medicare ID - Type Unspecified
A84501Medicare UPIN