Provider Demographics
NPI:1003977661
Name:BONA, JOHN-MICHAEL JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN-MICHAEL
Middle Name:JOSEPH
Last Name:BONA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:M
Other - Last Name:BONA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1 WIDGER RD
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-2146
Mailing Address - Country:US
Mailing Address - Phone:781-631-8300
Mailing Address - Fax:
Practice Address - Street 1:1 WIDGER RD
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-2146
Practice Address - Country:US
Practice Address - Phone:781-631-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0371530Medicaid
MAU67802Medicare UPIN
MABO W17180Medicare ID - Type Unspecified