MEDICARE: KOBY HIRAM BONILLA FERNANDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	24912	PR
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1962965616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOBY HIRAM BONILLA FERNANDEZ

Provider Business Mailing Address
First Line	:	10916 CALLE ATARDECER
Second Line	:
City	:	VILLALBA
State	:	PR
Zip	:	00766-2339
Country	:	US
Telephone Number	:	939-451-9776
Fax Number	:

Provider Business Practice Location Address
First Line	:	URB. ALTURAS DEL ALBA
Second Line	:	C. ATARDECER 10916
City	:	VILLALBA
State	:	PR
Zip	:	00766
Country	:	US
Telephone Number	:	939-451-9776
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2019
Last Update Date	:	06/05/2026

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Directions to “ KOBY HIRAM BONILLA FERNANDEZ ” Practice Location

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