Healthcare Provider Details

I. General information

NPI: 1265460851
Provider Name (Legal Business Name): MARICELA BONILLA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NORTH MUNDO
DULCE NM
87528-0187
US

IV. Provider business mailing address

PO BOX 187 500 NORTH MUNDO
DULCE NM
87528-0187
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-7281
  • Fax: 575-759-3651
Mailing address:
  • Phone: 575-759-7281
  • Fax: 575-759-3651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2334
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: