Provider Demographics
NPI:1689813024
Name:BONSOL, MICHAEL JEREMY DE MESA (DC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL JEREMY
Middle Name:DE MESA
Last Name:BONSOL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 COLE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-2601
Mailing Address - Country:US
Mailing Address - Phone:323-469-8062
Mailing Address - Fax:323-469-8064
Practice Address - Street 1:1011 COLE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-2601
Practice Address - Country:US
Practice Address - Phone:323-469-8062
Practice Address - Fax:323-469-8064
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011210111N00000X
CA32997111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210381Medicare UPIN