Provider Demographics
NPI:1578655601
Name:THORDARSON, BO HENRIETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:BO
Middle Name:HENRIETTE
Last Name:THORDARSON
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 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:#970-W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2199
Mailing Address - Country:US
Mailing Address - Phone:310-829-7878
Mailing Address - Fax:310-453-5586
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:#970-W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2199
Practice Address - Country:US
Practice Address - Phone:310-829-7878
Practice Address - Fax:310-453-5586
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51182174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG10890Medicare UPIN