Provider Demographics
NPI:1598970881
Name:BONETTO, NANCY MCKRELL (OD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:MCKRELL
Last Name:BONETTO
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 1:19547 SUNSHINE WAY
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1980
Mailing Address - Country:US
Mailing Address - Phone:541-330-8783
Mailing Address - Fax:
Practice Address - Street 1:19547 SUNSHINE WAY
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1980
Practice Address - Country:US
Practice Address - Phone:541-330-8783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2636ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU66577Medicare ID - Type Unspecified