MEDICARE: DR. GARY GILBERT BONNIN 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	605	AZ

General Provider Information

NPI Number	:	1598866881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GARY GILBERT BONNIN O.D.

Provider Business Mailing Address
First Line	:	23032 N 22ND WAY
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-9515
Country	:	US
Telephone Number	:	480-247-6224
Fax Number	:

Provider Business Practice Location Address
First Line	:	1646 W MONTEBELLO AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-2557
Country	:	US
Telephone Number	:	602-242-1105
Fax Number	:	602-293-4534

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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