Provider Demographics
NPI:1356804884
Name:BONU MOCHUNGONG, TAFOR NGWANU (MD)
Entity type:Individual
Prefix:
First Name:TAFOR
Middle Name:NGWANU
Last Name:BONU MOCHUNGONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TAFOR
Other - Middle Name:
Other - Last Name:BONU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3600 BROADWAY FL 4
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5730
Mailing Address - Country:US
Mailing Address - Phone:510-752-7826
Mailing Address - Fax:
Practice Address - Street 1:3600 BROADWAY FL 4
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5730
Practice Address - Country:US
Practice Address - Phone:510-752-7826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA180733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty