Provider Demographics
NPI:1235131384
Name:BOHAN, ANTHONY (MD JD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BOHAN
Suffix:
Gender:M
Credentials:MD JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 SUPERIOR AVE
Mailing Address - Street 2:#340
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2716
Mailing Address - Country:US
Mailing Address - Phone:949-645-7172
Mailing Address - Fax:949-642-7585
Practice Address - Street 1:320 SUPERIOR AVE
Practice Address - Street 2:#340
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2716
Practice Address - Country:US
Practice Address - Phone:949-645-7172
Practice Address - Fax:949-642-7585
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23845207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000002688OtherMEDICARE EMC
CA00A238450Medicaid
CA00A238450Medicaid
A23845Medicare ID - Type Unspecified