Provider Demographics
NPI:1992810592
Name:BONIFACE, DAVID R (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:BONIFACE
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 1:329 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-2114
Mailing Address - Country:US
Mailing Address - Phone:760-357-2712
Mailing Address - Fax:760-357-5710
Practice Address - Street 1:329 W 2ND ST
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-2114
Practice Address - Country:US
Practice Address - Phone:760-357-2712
Practice Address - Fax:760-357-5710
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6874T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0068740Medicaid
CAOP6874Medicare ID - Type Unspecified