Provider Demographics
NPI:1831295823
Name:BONOMO, GREGORY RALPH (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:RALPH
Last Name:BONOMO
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 1:1650 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4958
Mailing Address - Country:US
Mailing Address - Phone:714-549-6500
Mailing Address - Fax:
Practice Address - Street 1:1650 ADAMS AVE
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4958
Practice Address - Country:US
Practice Address - Phone:714-549-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG223822084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G223820Medicaid