Provider Demographics
NPI:1356572804
Name:BONACCI, DEREK JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:JOHN
Last Name:BONACCI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2055 15TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1747
Mailing Address - Country:US
Mailing Address - Phone:320-251-1432
Mailing Address - Fax:320-251-7122
Practice Address - Street 1:2055 15TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1747
Practice Address - Country:US
Practice Address - Phone:320-251-1432
Practice Address - Fax:320-251-7122
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3170152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist