Basic Information
| Provider Information | |||||||||
| NPI: | 1700834496 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLANNIGAN | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | DELL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1516 COTNER AVENUE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900253303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104452951 | ||||||||
| FaxNumber: | 3104791459 | ||||||||
| Practice Location | |||||||||
| Address1: | 2428 SANTA MONICA BLVD | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103151000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | A34520 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | A34520 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | A34520 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085D0003X | A34520 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging |
ID Information
| ID | Type | State | Issuer | Description | A34520 | 01 | CA | MEDICAL LICENSE | OTHER | GR0106035 | 05 | CA | MEDICAID | 00A345200 | 05 | CA | MEDICAID |