Provider Demographics
NPI:1760514343
Name:BONI, KIANSI (MD)
Entity Type:Individual
Prefix:
First Name:KIANSI
Middle Name:
Last Name:BONI
Suffix:
Gender:M
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:PO BOX 6299
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-0299
Mailing Address - Country:US
Mailing Address - Phone:805-486-9100
Mailing Address - Fax:805-486-7444
Practice Address - Street 1:650 HOBSON WAY # 209
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-6706
Practice Address - Country:US
Practice Address - Phone:805-486-9100
Practice Address - Fax:805-486-7444
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45536207Q00000X, 208000000X, 208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Not Answered207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A455360Medicaid
CAG04251Medicare UPIN
CA00A45536BMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER