Basic Information
| Provider Information | |||||||||
| NPI: | 1891068771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MASTERS | ||||||||
| FirstName: | BONNY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940633132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6507236661 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1555 SOQUEL DR | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950651705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314627700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2012 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | A119159 | CA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | A119159 | 01 | CA | LICENSE | OTHER |