Provider Demographics
NPI:1568466837
Name:BONO, KENNETH A (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:BONO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12116 STATE LINE RD
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66209
Mailing Address - Country:US
Mailing Address - Phone:913-808-5830
Mailing Address - Fax:913-808-5832
Practice Address - Street 1:12116 STATE LINE RD
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66209
Practice Address - Country:US
Practice Address - Phone:913-808-5830
Practice Address - Fax:913-808-5832
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1144-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200253510AMedicaid
KSKA2683004Medicare PIN
0000804AMedicare UPIN
KS200253510AMedicaid