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General NPI Number Information
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NPI Number | 1265460851
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Entity Type | Individual
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Provider Name | MARICELA BONILLA O.D.
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Gender | Female
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Dates
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Enumeration Date | 06/30/2006
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Last Update Date | 02/29/2012
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Provider Practice Location Address
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Address Line | 500 NORTH MUNDO
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City | DULCE
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State | NM
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Zip | 87528-0187
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Country | US
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Telephone | 575-759-7281
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Fax | 575-759-3651
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Provider Business Mailing Address
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Address Line | PO BOX 187 500 NORTH MUNDO
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City | DULCE
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State | NM
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Zip | 87528-0187
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Country | US
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Telephone | 575-759-7281
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Fax | 575-759-3651
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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 | 2334
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License Number State | CO
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