1871695924 NPI number — KAREN M BONTIA M.D.

Table of content: KAREN M BONTIA M.D. (NPI 1871695924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871695924 NPI number — KAREN M BONTIA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONTIA
Provider First Name:
KAREN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871695924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5425 W SPRING CREEK PKWY
Provider Second Line Business Mailing Address:
STE 275
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75024-4320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-253-4270
Provider Business Mailing Address Fax Number:
972-401-0458

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 N MACARTHUR BLVD
Provider Second Line Business Practice Location Address:
STE 150
Provider Business Practice Location Address City Name:
IRVING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75061-2219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-253-4270
Provider Business Practice Location Address Fax Number:
972-401-0458
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  N8078 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1484134 . This is a "CIGNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 432319099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7090704 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 098056 . This is a "ANTHEM BLUE SHIELD" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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