Healthcare Provider Details

I. General information

NPI: 1245630342
Provider Name (Legal Business Name): BONNIE LEBOFF M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 PRICE AVE SUITE 104
REDWOOD CITY CA
94063-1463
US

IV. Provider business mailing address

609 PRICE AVE SUITE 104
REDWOOD CITY CA
94063-1463
US

V. Phone/Fax

Practice location:
  • Phone: 650-365-1109
  • Fax: 650-365-7720
Mailing address:
  • Phone: 650-365-1109
  • Fax: 650-365-7720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG 61137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: