Basic Information
| Provider Information | |||||||||
| NPI: | 1588609549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BONIOL | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 919 HIDDEN RDG | ||||||||
| Address2: | FLOOR 6 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750383813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692822713 | ||||||||
| FaxNumber: | 4692822609 | ||||||||
| Practice Location | |||||||||
| Address1: | 1453 E BERT KOUNS INDUSTRIAL LOOP | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711056800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186814138 | ||||||||
| FaxNumber: | 3186814867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 200437 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207R00000X | 200437 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 194240102 | 05 | TX | MEDICAID | 1161608 | 05 | LA | MEDICAID | 1092631 | 05 | LA | MEDICAID |