Provider Demographics
NPI:1962445395
Name:FANELLI, BONNIE W (OD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:W
Last Name:FANELLI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:BONITA
Other - Middle Name:W
Other - Last Name:FANELLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1616 DOCTORS CIR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7406
Mailing Address - Country:US
Mailing Address - Phone:910-769-2740
Mailing Address - Fax:910-769-3622
Practice Address - Street 1:1616 DOCTORS CIR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7406
Practice Address - Country:US
Practice Address - Phone:910-769-2740
Practice Address - Fax:910-769-3622
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1187152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC09008OtherBCBSNC PROVIDER ID
NC7909008Medicaid
NC09008OtherBCBSNC PROVIDER ID
NCT65009Medicare UPIN
NCP00153653Medicare PIN