Healthcare Provider Details

I. General information

NPI: 1407854649
Provider Name (Legal Business Name): EDWIN BONILLA GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 CALLE MUNOZ RIVERA CALLE MUNOZ RIVERA 39
AGUAS BUENAS PR
00703-3233
US

IV. Provider business mailing address

PO BOX 4952 PO BOX 4952
CAGUAS PR
00726-4952
US

V. Phone/Fax

Practice location:
  • Phone: 787-732-7424
  • Fax: 787-732-7424
Mailing address:
  • Phone: 787-732-7424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number11614
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: