Healthcare Provider Details

I. General information

NPI: 1205039757
Provider Name (Legal Business Name): JUAN SAMUEL IGNACIO BONILLA-PEREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 LIBERTY AVE
BROOKLYN NY
11208-2922
US

IV. Provider business mailing address

PO BOX 746087
ATLANTA GA
30374-6087
US

V. Phone/Fax

Practice location:
  • Phone: 718-765-6058
  • Fax: 347-808-4895
Mailing address:
  • Phone: 833-804-1695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number16664
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD048978
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number292251
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: