Provider Demographics
NPI:1154492510
Name:BONELLI, CHARLES A (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:BONELLI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:CANTON VILLAGE
Mailing Address - City:CANTON
Mailing Address - State:CT
Mailing Address - Zip Code:06019-0014
Mailing Address - Country:US
Mailing Address - Phone:860-693-2289
Mailing Address - Fax:860-693-1835
Practice Address - Street 1:220 ALBANY TPKE
Practice Address - Street 2:CANTON VILLAGE
Practice Address - City:CANTON
Practice Address - State:CT
Practice Address - Zip Code:06019-2520
Practice Address - Country:US
Practice Address - Phone:860-639-2289
Practice Address - Fax:860-693-1835
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000763152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTT23293Medicare UPIN