Healthcare Provider Details

I. General information

NPI: 1235803586
Provider Name (Legal Business Name): SEBASTIAN ALEXIS BONILLA BENITEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 AVE GENERAL VALERO
FAJARDO PR
00738-3998
US

IV. Provider business mailing address

URB VEVE CALZADA CALLE 3A O28
FAJARDO PR
00738
US

V. Phone/Fax

Practice location:
  • Phone: 787-655-0505
  • Fax:
Mailing address:
  • Phone: 787-602-2923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number23372
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: