Provider Demographics
NPI:1902886393
Name:BONGARD, FREDERIC (MD)
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:
Last Name:BONGARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21840 NORMANDIE AVE
Mailing Address - Street 2:STE. 700
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2047
Mailing Address - Country:US
Mailing Address - Phone:310-222-5189
Mailing Address - Fax:310-782-6786
Practice Address - Street 1:21840 S NORMANDIE AVE
Practice Address - Street 2:STE. 700
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2047
Practice Address - Country:US
Practice Address - Phone:310-222-5189
Practice Address - Fax:310-782-6786
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG433072086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG43307FMedicare ID - Type UnspecifiedPPIN
CAWG43307GMedicare ID - Type UnspecifiedPPIN
CAWG43307EMedicare ID - Type UnspecifiedPPIN
CAA49305Medicare UPIN