Provider Demographics
NPI:1891068771
Name:MASTERS, BONNY (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNY
Middle Name:
Last Name:MASTERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-3132
Mailing Address - Country:US
Mailing Address - Phone:650-723-6661
Mailing Address - Fax:
Practice Address - Street 1:1555 SOQUEL DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1705
Practice Address - Country:US
Practice Address - Phone:831-462-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119159208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA119159OtherLICENSE