Provider Demographics
NPI:1265637714
Name:BONITA POINT FAMILY OPTOMETRY, INC.
Entity Type:Organization
Organization Name:BONITA POINT FAMILY OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:LUTHER
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:619-267-9900
Mailing Address - Street 1:180 OTAY LAKES RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-2443
Mailing Address - Country:US
Mailing Address - Phone:619-267-9900
Mailing Address - Fax:619-267-9910
Practice Address - Street 1:180 OTAY LAKES RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-2443
Practice Address - Country:US
Practice Address - Phone:619-267-9900
Practice Address - Fax:619-267-9910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7989TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1841406394OtherNPI
CASD0079890Medicaid
CA1841208840OtherNPI
1841406394OtherNPI
CA1841208840OtherNPI