Basic Information
| Provider Information | |||||||||
| NPI: | 1992827653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONG | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | JANEL HAYWOOD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., FAAP, M.P.H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7625 SLATE CT | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809192922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193133267 | ||||||||
| FaxNumber: | 7193096847 | ||||||||
| Practice Location | |||||||||
| Address1: | 2960 N CIRCLE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809091163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196348891 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 47375 | CO | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | LL28136 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 37336843 | 05 | CO | MEDICAID | BB9436230 | 01 | SC | FEDERAL DEA | OTHER | LL28136 | 01 | SC | LIMITED MEDICAL LICENSE | OTHER | CO306759 | 01 | CO | MEDICARE PTAN | OTHER | 47375 | 01 | CO | MEDICAL LICENSE | OTHER | FB1340912 | 01 | CO | DEA | OTHER |