Provider Demographics
NPI:1245224377
Name:VESTAL, BONITA KLAHN (MD)
Entity Type:Individual
Prefix:DR
First Name:BONITA
Middle Name:KLAHN
Last Name:VESTAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BONNIE
Other - Middle Name:
Other - Last Name:VESTAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1502 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4028
Mailing Address - Country:US
Mailing Address - Phone:208-385-7868
Mailing Address - Fax:208-344-3059
Practice Address - Street 1:1502 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4028
Practice Address - Country:US
Practice Address - Phone:208-385-7868
Practice Address - Fax:208-344-3059
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-37132080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1142700Medicare ID - Type Unspecified