Healthcare Provider Details

I. General information

NPI: 1255696654
Provider Name (Legal Business Name): ESTEBAN BONFANTE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NEWBURY RD SUITE 285
NEWBURY PARK CA
91320-6435
US

IV. Provider business mailing address

PO BOX 3098
TORRANCE CA
90510-3098
US

V. Phone/Fax

Practice location:
  • Phone: 805-376-0277
  • Fax: 805-376-0244
Mailing address:
  • Phone: 310-792-3914
  • Fax: 855-898-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA86766
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberA86766
License Number StateCA

VIII. Authorized Official

Name: ESTEBAN BONFANTE
Title or Position: PRESIDENT/ OWNER
Credential: M.D.
Phone: 310-792-3914