Provider Demographics
NPI:1285680835
Name:BONSUKAN, EULOGIO (MD)
Entity Type:Individual
Prefix:
First Name:EULOGIO
Middle Name:
Last Name:BONSUKAN
Suffix:
Gender:M
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:PO BOX 8549
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-0549
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:817-563-3699
Practice Address - Street 1:1612 S HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3518
Practice Address - Country:US
Practice Address - Phone:903-984-3505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9119207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0028EWOtherBCBS
TXB21378Medicare UPIN
TX00279MMedicare PIN