Basic Information
| Provider Information | |||||||||
| NPI: | 1003809211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENALES | ||||||||
| FirstName: | LEA | ||||||||
| MiddleName: | BONIFACIO | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BONIFACIO | ||||||||
| OtherFirstName: | LEA | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1202 LOUISIANA AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711013910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182128946 | ||||||||
| FaxNumber: | 3182124153 | ||||||||
| Practice Location | |||||||||
| Address1: | 2520 BERT KOUNS LOOP | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711183130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182125970 | ||||||||
| FaxNumber: | 3182125975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 12/07/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 4301084897 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080N0001X | MA73968 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080N0001X | 40150 | CT | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080N0001X | 203321 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1816680 | 05 | LA | MEDICAID |