Provider Demographics
NPI:1265460851
Name:BONILLA, MARICELA (OD)
Entity Type:Individual
Prefix:
First Name:MARICELA
Middle Name:
Last Name:BONILLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:500 NORTH MUNDO
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:575-759-7281
Mailing Address - Fax:575-759-3651
Practice Address - Street 1:500 NORTH MUNDO
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-0187
Practice Address - Country:US
Practice Address - Phone:575-759-7281
Practice Address - Fax:575-759-3651
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2334152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM23721243Medicaid
NMK3526OtherFACILITY MEDICAID
NMHSZ196OtherMEDICARE PART B
NM23721243Medicaid
NM8HH399Medicare PIN