Provider Demographics
NPI:1861912461
Name:WESSLER, BONNIE MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:MARIE
Last Name:WESSLER
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 1:5670 OLD WINDER HWY STE 201
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-1240
Mailing Address - Country:US
Mailing Address - Phone:770-927-4537
Mailing Address - Fax:
Practice Address - Street 1:4359 35TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33714-3717
Practice Address - Country:US
Practice Address - Phone:727-525-3959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC6201152W00000X
GAOPT003285152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX386292201Medicaid