Healthcare Provider Details

I. General information

NPI: 1417514811
Provider Name (Legal Business Name): RUBEN BONILLA GUERRERO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 CORPORATE BLVD STE D
SOUTH PLAINFIELD NJ
07080-2411
US

IV. Provider business mailing address

126 CORPORATE BLVD STE D
SOUTH PLAINFIELD NJ
07080-2411
US

V. Phone/Fax

Practice location:
  • Phone: 908-222-0533
  • Fax:
Mailing address:
  • Phone: 908-222-0533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0202X
TaxonomyClinical Biochemical Genetics Physician
License NumberCQP92933
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License NumberCQP92933
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: