Provider Demographics
NPI:1700834496
Name:FLANNIGAN, BONNIE DELL (MD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:DELL
Last Name:FLANNIGAN
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 1:1516 COTNER AVENUE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3303
Mailing Address - Country:US
Mailing Address - Phone:310-445-2951
Mailing Address - Fax:310-479-1459
Practice Address - Street 1:2428 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2045
Practice Address - Country:US
Practice Address - Phone:310-315-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA345202085B0100X, 2085N0700X, 2085R0202X, 2085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Neuroimaging
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34520OtherMEDICAL LICENSE
CAGR0106035Medicaid
CA00A345200Medicaid
CAA34520OtherMEDICAL LICENSE
CAWA34520QMedicare PIN
CA00A345200Medicaid
CAGR0106035Medicaid