Provider Demographics
NPI:1225226558
Name:BOCK, BONNIE VIRGINIA (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:VIRGINIA
Last Name:BOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SUPERIOR AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663
Mailing Address - Country:US
Mailing Address - Phone:949-645-9010
Mailing Address - Fax:949-645-1003
Practice Address - Street 1:1501 SUPERIOR AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663
Practice Address - Country:US
Practice Address - Phone:949-645-9010
Practice Address - Fax:949-645-1003
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35572207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G355720Medicaid
CAA91697Medicare UPIN