Provider Demographics
NPI:1992706220
Name:BONNER, ROBERT (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:BONNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14595 OLYMPIC DR
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-9100
Mailing Address - Country:US
Mailing Address - Phone:707-994-1488
Mailing Address - Fax:707-994-8108
Practice Address - Street 1:14595 OLYMPIC DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9100
Practice Address - Country:US
Practice Address - Phone:707-994-1488
Practice Address - Fax:707-994-8108
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5079T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0050790Medicaid
CASD0050790Medicaid
CA5564320001Medicare NSC
CASD0050790Medicare PIN