Provider Demographics
NPI:1114662913
Name:QUACH, BONNIE
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:
Last Name:QUACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-1783
Mailing Address - Country:US
Mailing Address - Phone:857-204-9525
Mailing Address - Fax:
Practice Address - Street 1:603 CONCORD AVE STE B
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1380
Practice Address - Country:US
Practice Address - Phone:617-945-2906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA5532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program