Provider Demographics
NPI:1619168150
Name:BONIFACE O ONUBAH, M.D. INC.
Entity Type:Organization
Organization Name:BONIFACE O ONUBAH, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:BONIFACE
Authorized Official - Middle Name:O
Authorized Official - Last Name:ONUBAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-702-5100
Mailing Address - Street 1:2501 W BURBANK BLVD
Mailing Address - Street 2:308
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-2347
Mailing Address - Country:US
Mailing Address - Phone:310-207-5100
Mailing Address - Fax:818-557-6491
Practice Address - Street 1:2501 W BURBANK BLVD
Practice Address - Street 2:308
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-2347
Practice Address - Country:US
Practice Address - Phone:310-207-5100
Practice Address - Fax:818-557-6491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52415207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52415OtherMEDICAL LICENSE