Provider Demographics
NPI:1992772784
Name:BONGIOVANNI, MICHAEL S (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:BONGIOVANNI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 4TH AVE
Mailing Address - Street 2:SUITE 630
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-299-3950
Mailing Address - Fax:619-299-3951
Practice Address - Street 1:4060 4TH AVE
Practice Address - Street 2:SUITE 630
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-299-3950
Practice Address - Fax:619-299-3951
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59386207X00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4858980001OtherCIGNA MEDICARE DMERC
CA00G593860Medicaid
CA200042516OtherRR MEDICARE
CA200042516OtherRR MEDICARE
CA4858980001OtherCIGNA MEDICARE DMERC