Basic Information
| Provider Information | |||||||||
| NPI: | 1720633597 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BONNY MASTERS MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 STANDIFORD AVE STE F | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953501159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095795628 | ||||||||
| FaxNumber: | 2095795637 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 SOQUEL DR | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950651705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096614403 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2019 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | MASTERS | ||||||||
| AuthorizedOfficialFirstName: | BONNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8315396719 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.