Healthcare Provider Details

I. General information

NPI: 1528590775
Provider Name (Legal Business Name): KEVIN ANDREW BONILLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 E HERNDON AVE
FRESNO CA
93720-3309
US

IV. Provider business mailing address

2108 N ST # 8172
SACRAMENTO CA
95816-5712
US

V. Phone/Fax

Practice location:
  • Phone: 732-804-8490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA184981
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: