Healthcare Provider Details

I. General information

NPI: 1508374489
Provider Name (Legal Business Name): DAVID C BONOVICH MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2018
Last Update Date: 10/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20103 LAKE CHABOT RD
CASTRO VALLEY CA
94546-5305
US

IV. Provider business mailing address

14780 SW OSPREY DR STE 325
BEAVERTON OR
97007-8069
US

V. Phone/Fax

Practice location:
  • Phone: 503-579-5000
  • Fax: 503-579-5001
Mailing address:
  • Phone: 503-579-5000
  • Fax: 503-579-5001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberG71726
License Number StateCA

VIII. Authorized Official

Name: LEANE WADSWORTH
Title or Position: OFFICE MANAGER
Credential:
Phone: 503-579-5000