Provider Demographics
NPI:1508179789
Name:JOHN M BONA O.D. PC
Entity Type:Organization
Organization Name:JOHN M BONA O.D. PC
Other - Org Name:CUSTOM EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BONA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:781-592-0000
Mailing Address - Street 1:430 PARADISE RD
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-1354
Mailing Address - Country:US
Mailing Address - Phone:781-592-0000
Mailing Address - Fax:781-593-8133
Practice Address - Street 1:430 PARADISE RD
Practice Address - Street 2:
Practice Address - City:SWAMPSCOTT
Practice Address - State:MA
Practice Address - Zip Code:01907-1354
Practice Address - Country:US
Practice Address - Phone:781-592-0000
Practice Address - Fax:781-593-8133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W17180Medicare PIN
MAU67802Medicare UPIN
W17180Medicare Oscar/Certification