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General NPI Number Information
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NPI Number | 1073139291
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Entity Type | Individual
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Provider Name | BONNIE LAUREN SAMUELSON OD
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Gender | Female
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Dates
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Enumeration Date | 06/23/2020
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Last Update Date | 06/23/2020
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Provider Practice Location Address
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Address Line | 21161 NEWPORT COAST DR
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City | NEWPORT BEACH
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State | CA
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Zip | 92657-1123
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Country | US
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Telephone | 949-640-4733
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Fax | 949-287-0186
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Provider Business Mailing Address
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Address Line | 9862 KINGS CANYON DR
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92646-4829
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Country | US
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Telephone | 714-745-9312
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 34540
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License Number State | CA
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