Provider Demographics
NPI:1891755229
Name:WEINGARTEN, BONNY MAE (OD)
Entity Type:Individual
Prefix:MRS
First Name:BONNY
Middle Name:MAE
Last Name:WEINGARTEN
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 1:29 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930
Mailing Address - Country:US
Mailing Address - Phone:978-281-4514
Mailing Address - Fax:978-281-4668
Practice Address - Street 1:29 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930
Practice Address - Country:US
Practice Address - Phone:978-281-4514
Practice Address - Fax:978-281-4668
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA3399TP152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0355917Medicaid
MA0355917Medicaid