Provider Demographics
NPI:1720321177
Name:BONNETT, CHARLES A (MD,)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:BONNETT
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 1:10990 WARNER AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3849
Mailing Address - Country:US
Mailing Address - Phone:714-964-4511
Mailing Address - Fax:714-964-9305
Practice Address - Street 1:10990 WARNER AVE
Practice Address - Street 2:SUITE D
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3849
Practice Address - Country:US
Practice Address - Phone:714-964-4511
Practice Address - Fax:714-964-9305
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG8333174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG8333OtherTHE MEDICAL BOARD OF CALIFORNIA