Healthcare Provider Details

I. General information

NPI: 1891806121
Provider Name (Legal Business Name): EDWIN R BONILLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 W 8TH ST
DERIDDER LA
70634-5507
US

IV. Provider business mailing address

901 BIRCH DR
DERIDDER LA
70634-5308
US

V. Phone/Fax

Practice location:
  • Phone: 337-463-8977
  • Fax: 337-462-3093
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number08674
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: