Healthcare Provider Details

I. General information

NPI: 1477129054
Provider Name (Legal Business Name): O'MALLEY MARIE BOSANIC OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27499 RIVERVIEW CENTER BLVD STE 429
BONITA SPRINGS FL
34134-4342
US

IV. Provider business mailing address

27499 RIVERVIEW CENTER BLVD STE 429
BONITA SPRINGS FL
34134-4342
US

V. Phone/Fax

Practice location:
  • Phone: 866-604-2931
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5984
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3942
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: