Healthcare Provider Details

I. General information

NPI: 1215951934
Provider Name (Legal Business Name): PEDRO BONILLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 GORE ST EAST CAMBRIDGE HEALTH CENTER
EAST CAMBRIDGE MA
02141-1119
US

IV. Provider business mailing address

163 GORE ST EAST CAMBRIDGE HEALTH CENTER
EAST CAMBRIDGE MA
02141-1119
US

V. Phone/Fax

Practice location:
  • Phone: 617-665-3000
  • Fax:
Mailing address:
  • Phone: 617-665-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number227286
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: