Provider Demographics
NPI:1407835994
Name:BONTU, RUPA (MD)
Entity Type:Individual
Prefix:
First Name:RUPA
Middle Name:
Last Name:BONTU
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 1:4626 PROGRESS DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3483
Mailing Address - Country:US
Mailing Address - Phone:563-441-9100
Mailing Address - Fax:563-441-9101
Practice Address - Street 1:4626 PROGRESS DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3483
Practice Address - Country:US
Practice Address - Phone:563-441-9100
Practice Address - Fax:563-441-9101
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24346207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C43143Medicare UPIN