Provider Demographics
NPI:1932132024
Name:BONAME, MARY ELLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELLEN
Last Name:BONAME
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 1:1325 US HIGHWAY 206
Mailing Address - Street 2:SUITE 24
Mailing Address - City:SKILLMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08558-1922
Mailing Address - Country:US
Mailing Address - Phone:609-279-0005
Mailing Address - Fax:609-279-0004
Practice Address - Street 1:1325 US HIGHWAY 206
Practice Address - Street 2:SUITE 24
Practice Address - City:SKILLMAN
Practice Address - State:NJ
Practice Address - Zip Code:08558-1922
Practice Address - Country:US
Practice Address - Phone:609-279-0005
Practice Address - Fax:609-279-0004
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOA-05298152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU68327Medicare UPIN