Provider Demographics
NPI:1407849318
Name:MALLARD, BONNIE E (OD)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:E
Last Name:MALLARD
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 1:826 SAVANNAH LN
Mailing Address - Street 2:
Mailing Address - City:CALERA
Mailing Address - State:AL
Mailing Address - Zip Code:35040-5553
Mailing Address - Country:US
Mailing Address - Phone:205-835-1320
Mailing Address - Fax:
Practice Address - Street 1:1415 7TH ST S
Practice Address - Street 2:
Practice Address - City:CLANTON
Practice Address - State:AL
Practice Address - Zip Code:35045-3746
Practice Address - Country:US
Practice Address - Phone:205-755-7114
Practice Address - Fax:205-755-8142
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-BO9-TA-693152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist