Provider Demographics
NPI:1538190400
Name:LARGE, BONNIE SHUBERT (OD)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:SHUBERT
Last Name:LARGE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14509 ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-1236
Mailing Address - Country:US
Mailing Address - Phone:913-669-6665
Mailing Address - Fax:
Practice Address - Street 1:5110 N OAK TRFY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-4621
Practice Address - Country:US
Practice Address - Phone:816-459-7633
Practice Address - Fax:816-454-0681
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1494-3152W00000X
MOT03392152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist