Healthcare Provider Details

I. General information

NPI: 1124120902
Provider Name (Legal Business Name): MICHAEL T BONTEKOE MS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 11/02/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N ROXBURY DR STE 400
BEVERLY HILLS CA
90210-4218
US

IV. Provider business mailing address

450 N ROXBURY DR STE 400
BEVERLY HILLS CA
90210-4218
US

V. Phone/Fax

Practice location:
  • Phone: 243-941-6104
  • Fax: 424-394-1628
Mailing address:
  • Phone: 424-394-1610
  • Fax: 424-394-1628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA16231
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA16231
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: