Provider Demographics
NPI:1275500662
Name:FUNG, BONITA R Y (MD)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:R Y
Last Name:FUNG
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:DEPT 781676
Mailing Address - Street 2:PO BOX 78000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1676
Mailing Address - Country:US
Mailing Address - Phone:614-722-5315
Mailing Address - Fax:614-722-3033
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-5315
Practice Address - Fax:614-722-3033
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086003F207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2601107Medicaid
I38767Medicare UPIN
OH2601107Medicaid