Healthcare Provider Details

I. General information

NPI: 1073662060
Provider Name (Legal Business Name): BONAVENTURE F ENG MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 10/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 LYNN RD SUITE 104
THOUSAND OAKS CA
91360-1901
US

IV. Provider business mailing address

2230 LYNN ROAD SUITE 104
THOUSAND OAKS CA
91360
US

V. Phone/Fax

Practice location:
  • Phone: 806-497-0961
  • Fax: 806-496-4818
Mailing address:
  • Phone: 806-497-0961
  • Fax: 806-496-4818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG22291
License Number StateCA

VIII. Authorized Official

Name: BONAVENTURE F ENG
Title or Position: OWNER
Credential: MD
Phone: 805-497-0961