Provider Demographics
NPI:1760422661
Name:FISKE, BONNIE JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:JEAN
Last Name:FISKE
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 1:2464 HWY 6 AND 50
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-1138
Mailing Address - Country:US
Mailing Address - Phone:970-241-9299
Mailing Address - Fax:970-241-1191
Practice Address - Street 1:2464 HWY 6 AND 50
Practice Address - Street 2:SUITE 110
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-1138
Practice Address - Country:US
Practice Address - Phone:970-241-9299
Practice Address - Fax:970-241-1191
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1945152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC486088Medicare PIN
U63965Medicare UPIN