Provider Demographics
NPI:1588668917
Name:BONAKDAR, ALEXANDER M (OD)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:M
Last Name:BONAKDAR
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 1:801 N TUSTIN AVE
Mailing Address - Street 2:STE 404
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3608
Mailing Address - Country:US
Mailing Address - Phone:714-558-1182
Mailing Address - Fax:
Practice Address - Street 1:801 N TUSTIN AVE
Practice Address - Street 2:STE 404
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3608
Practice Address - Country:US
Practice Address - Phone:714-558-1182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9763T152W00000X
CAOP9763152WC0802X
CAOPT9763152WX0102X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU32566Medicare UPIN