Provider Demographics
NPI:1437404415
Name:WONG, BONNIE (DO)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3752
Mailing Address - Country:US
Mailing Address - Phone:206-999-3950
Mailing Address - Fax:
Practice Address - Street 1:902 LAKEVIEW AVE
Practice Address - Street 2:SOUTHERN COLORADO FAMILY MEDICINE
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3798
Practice Address - Country:US
Practice Address - Phone:719-557-5872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL-4526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COTL-4526OtherCOLORADO TRAINING LICENSE NUMBER