Provider Demographics
NPI:1457387805
Name:BONILLA-TANDOC, SHEILA MARIE (MD, MS)
Entity type:Individual
Prefix:DR
First Name:SHEILA
Middle Name:MARIE
Last Name:BONILLA-TANDOC
Suffix:
Gender:F
Credentials:MD, MS
Other - Prefix:DR
Other - First Name:SHEILA
Other - Middle Name:MARIE
Other - Last Name:BONILLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, MS
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5100
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST STE 1000
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5312
Practice Address - Country:US
Practice Address - Phone:323-442-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69281207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A692810OtherBLUE SHIELD
CA00A692810Medicaid
CA1356390009OtherGROUP NPI
CA00A692810197OtherCAL OPTIMA
CAGR0016910OtherGROUP MEDICAID PIN
CAW11675OtherGROUP MEDICARE PIN
CACE1617OtherGROUP RAILROAD MEDICARE
CA00A692810197OtherCAL OPTIMA
CAW11675OtherGROUP MEDICARE PIN