Basic Information
| Provider Information | |||||||||
| NPI: | 1285680835 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONSUKAN | ||||||||
| FirstName: | EULOGIO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8549 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761240549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174514208 | ||||||||
| FaxNumber: | 8175633699 | ||||||||
| Practice Location | |||||||||
| Address1: | 1612 S HENDERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | KILGORE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756623518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039843505 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 02/01/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | E9119 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0028EW | 01 | TX | BCBS | OTHER |