Healthcare Provider Details

I. General information

NPI: 1558327015
Provider Name (Legal Business Name): JUAN JOSE BONILLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 N HIGHLAND AVE
AURORA IL
60506-1449
US

IV. Provider business mailing address

2650 WARRENVILLE RD STE 280
DOWNERS GROVE IL
60515-1721
US

V. Phone/Fax

Practice location:
  • Phone: 630-801-5700
  • Fax: 630-801-5704
Mailing address:
  • Phone: 630-324-7900
  • Fax: 630-271-1813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number1049084
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036083958
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: