Provider Demographics
NPI:1427076207
Name:BONUAN, TEODORA M (MD)
Entity type:Individual
Prefix:
First Name:TEODORA
Middle Name:M
Last Name:BONUAN
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:PO BOX 4419
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-4419
Mailing Address - Country:US
Mailing Address - Phone:818-340-9988
Mailing Address - Fax:818-587-2493
Practice Address - Street 1:3350 W BALL RD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3710
Practice Address - Country:US
Practice Address - Phone:714-220-4533
Practice Address - Fax:818-587-2493
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33697207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A336970OtherBLUE SHIELD
CA00A336970Medicaid
CA00A336970Medicaid
CAWA33697EMedicare ID - Type Unspecified