Provider Demographics
NPI:1770677247
Name:BOHUN, THERESA ROSE (MD)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ROSE
Last Name:BOHUN
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 1:3260 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5616
Mailing Address - Country:US
Mailing Address - Phone:619-297-3737
Mailing Address - Fax:619-297-0443
Practice Address - Street 1:3260 THIRD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1323
Practice Address - Country:US
Practice Address - Phone:619-297-3737
Practice Address - Fax:619-297-0443
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA952585978OtherCHAMPUS
CAG77440OtherBLUE CROSS
CAG77440OtherPPO/COMM
CAG77440OtherHMO
AR006774400OtherBLUE SHIELD
CA00G774400Medicaid
CAWG77440AMedicare ID - Type Unspecified
CAG05812Medicare UPIN