Healthcare Provider Details

I. General information

NPI: 1992772784
Provider Name (Legal Business Name): MICHAEL S BONGIOVANNI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 4TH AVE SUITE 630
SAN DIEGO CA
92103-2116
US

IV. Provider business mailing address

4060 4TH AVE SUITE 630
SAN DIEGO CA
92103-2116
US

V. Phone/Fax

Practice location:
  • Phone: 619-299-3950
  • Fax: 619-299-3951
Mailing address:
  • Phone: 619-299-3950
  • Fax: 619-299-3951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG59386
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG59386
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: