MEDICARE: MARICELA BONILLA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2334	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	HSZ196	OTHER	NM	MEDICARE PART B

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265460851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARICELA BONILLA O.D.

Provider Business Mailing Address
First Line	:	PO BOX 187
Second Line	:	500 NORTH MUNDO
City	:	DULCE
State	:	NM
Zip	:	87528-0187
Country	:	US
Telephone Number	:	575-759-7281
Fax Number	:	575-759-3651

Provider Business Practice Location Address
First Line	:	500 NORTH MUNDO
Second Line	:
City	:	DULCE
State	:	NM
Zip	:	87528-0187
Country	:	US
Telephone Number	:	575-759-7281
Fax Number	:	575-759-3651

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	02/29/2012

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Directions to “ MARICELA BONILLA O.D.” Practice Location

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