1265460851 NPI number — MARICELA BONILLA O.D.

Table of content: MARICELA BONILLA O.D. (NPI 1265460851)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265460851 NPI number — MARICELA BONILLA O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BONILLA
Provider First Name:
MARICELA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265460851
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 187
Provider Second Line Business Mailing Address:
500 NORTH MUNDO
Provider Business Mailing Address City Name:
DULCE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87528-0187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-759-7281
Provider Business Mailing Address Fax Number:
575-759-3651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 NORTH MUNDO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULCE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87528-0187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-759-7281
Provider Business Practice Location Address Fax Number:
575-759-3651
Provider Enumeration Date:
06/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2334 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 23721243 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: K3526 . This is a "FACILITY MEDICAID" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: HSZ196 . This is a "MEDICARE PART B" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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