=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437404415
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BONNIE WONG DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2012
-----------------------------------------------------
Last Update Date | 07/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 902 LAKEVIEW AVE SOUTHERN COLORADO FAMILY MEDICINE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-3798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-557-5872
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2116 WYOMING AVE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-3752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-999-3950
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | TL-4526
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------