Provider Demographics
NPI:1073662060
Name:BONAVENTURE F ENG MD INC
Entity Type:Organization
Organization Name:BONAVENTURE F ENG MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BONAVENTURE
Authorized Official - Middle Name:F
Authorized Official - Last Name:ENG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-497-0961
Mailing Address - Street 1:2230 LYNN ROAD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360
Mailing Address - Country:US
Mailing Address - Phone:806-497-0961
Mailing Address - Fax:806-496-4818
Practice Address - Street 1:2230 LYNN RD
Practice Address - Street 2:SUITE 104
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1901
Practice Address - Country:US
Practice Address - Phone:806-497-0961
Practice Address - Fax:806-496-4818
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BONAVENTURE F ENG MD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-09
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22291207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G222910Medicaid
A89356Medicare UPIN
CAG22291Medicare ID - Type Unspecified