Basic Information
| Provider Information | |||||||||
| NPI: | 1184696064 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BONU | ||||||||
| FirstName: | COMFORT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | PHYSICIAN PRACTICES | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059896130 | ||||||||
| FaxNumber: | 5058205408 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 SAINT MICHAELS DR | ||||||||
| Address2: | ST. VINCENT HOSPITALIST GROUP | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059896130 | ||||||||
| FaxNumber: | 5058205408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 01/23/2015 | ||||||||
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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 | 208000000X | 01049085A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | MD2010-0050 | NM | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | MD2010-0050 | NM | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | MD2010-0050 | NM | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 200200060 | 05 | IN | MEDICAID |