Healthcare Provider Details

I. General information

NPI: 1174227425
Provider Name (Legal Business Name): FLAVIO FERNANDO BONILLA MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 W 10TH AVE
COLUMBUS OH
43210-1240
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-7499
  • Fax: 614-366-2360
Mailing address:
  • Phone: 614-293-7499
  • Fax: 614-366-2360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.156398
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.156398
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: