Provider Demographics
NPI:1508374489
Name:DAVID C BONOVICH MD
Entity Type:Organization
Organization Name:DAVID C BONOVICH MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WADSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-579-5000
Mailing Address - Street 1:14780 SW OSPREY DR STE 325
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-8069
Mailing Address - Country:US
Mailing Address - Phone:503-579-5000
Mailing Address - Fax:503-579-5001
Practice Address - Street 1:20103 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5305
Practice Address - Country:US
Practice Address - Phone:503-579-5000
Practice Address - Fax:503-579-5001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-13
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG717262084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular NeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7587738Medicaid