Provider Demographics
NPI:1861649345
Name:BONELLI, LAURA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BONELLI
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 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-825-5000
Mailing Address - Fax:
Practice Address - Street 1:100 STEIN PLAZA
Practice Address - Street 2:RM# 1-340
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-7001
Practice Address - Country:US
Practice Address - Phone:310-825-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117107207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00F54820Medicaid
CAAS133ZMedicare PIN
CA00F54820Medicaid