Provider Demographics
NPI:1487628459
Name:MOURA, BONNIE TEKLIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:TEKLIN
Last Name:MOURA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:818-952-3075
Mailing Address - Fax:818-790-2215
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:818-952-3075
Practice Address - Fax:818-790-2215
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG061553207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902846306OtherGROUP NPI
CAW18762OtherGROUP MEDICARE
CAGR0100430OtherGROUP MEDICAL
CA1902846306OtherGROUP NPI