Healthcare Provider Details

I. General information

NPI: 1861170961
Provider Name (Legal Business Name): ABDON BALTAZAR BONILLA CAMPOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2023
Last Update Date: 07/09/2023
Certification Date: 07/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE
NEW YORK NY
10029-7491
US

IV. Provider business mailing address

718 W 178TH ST APT 25
NEW YORK NY
10033-6439
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6262
  • Fax:
Mailing address:
  • Phone: 571-376-1379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: