Healthcare Provider Details

I. General information

NPI: 1639794670
Provider Name (Legal Business Name): CARLA MARIE ONGLENGCO BOZON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date: 01/18/2022
Reactivation Date: 02/24/2022

III. Provider practice location address

45124 10TH ST W
LANCASTER CA
93534-2310
US

IV. Provider business mailing address

45124 10TH ST W
LANCASTER CA
93534-2310
US

V. Phone/Fax

Practice location:
  • Phone: 562-867-7999
  • Fax:
Mailing address:
  • Phone: 562-867-7999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA188298
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: