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General NPI Number Information
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NPI Number | 1508374489
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Entity Type | Organization
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Legal Business Name | DAVID C BONOVICH MD
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Dates
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Enumeration Date | 01/13/2018
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Last Update Date | 10/08/2018
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Provider Practice Location Address
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Address Line | 20103 LAKE CHABOT RD
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City | CASTRO VALLEY
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State | CA
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Zip | 94546-5305
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Country | US
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Telephone | 503-579-5000
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Fax | 503-579-5001
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Provider Business Mailing Address
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Address Line | 14780 SW OSPREY DR STE 325
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City | BEAVERTON
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State | OR
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Zip | 97007-8069
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Country | US
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Telephone | 503-579-5000
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Fax | 503-579-5001
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LEANE WADSWORTH
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Credential |
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Telephone | 503-579-5000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084V0102X
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Taxonomy Name | Vascular Neurology Physician
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License Number | G71726
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License Number State | CA
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