Healthcare Provider Details

I. General information

NPI: 1780094755
Provider Name (Legal Business Name): JEFFREY BONENFANT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2185 CITRACADO PKWY
ESCONDIDO CA
92029-4159
US

IV. Provider business mailing address

302 WASHINGTON ST # 153
SAN DIEGO CA
92103-2110
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2896
  • Fax:
Mailing address:
  • Phone: 909-558-2896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number20A14615
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number20A14615
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: