Provider Demographics
NPI:1508955873
Name:BONNANZIO, KAREN GRANTE (OD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:GRANTE
Last Name:BONNANZIO
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 1:7365 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-1300
Mailing Address - Country:US
Mailing Address - Phone:203-377-3937
Mailing Address - Fax:888-741-0620
Practice Address - Street 1:7365 MAIN ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-1300
Practice Address - Country:US
Practice Address - Phone:203-377-3937
Practice Address - Fax:888-741-0620
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002346152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004160983Medicaid
CT020346OtherCONNECTICARE
CT50ORONOQUCT01OtherANTHEM
CT1040121OtherWELLCARE
CT115529OtherEYEMED
CT0297743OtherAETNA
CT1801834247OtherOXFORD
CT204142248OtherCIGNA
CT004160983Medicaid
CT1040121OtherWELLCARE