Healthcare Provider Details

I. General information

NPI: 1588790463
Provider Name (Legal Business Name): GISEL MARIE BONILLA REYES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CLINICA YAGUEZ CALLE ESTACION 117
MAYAGUEZ PR
00680
US

IV. Provider business mailing address

FARAYON 3333 URB ALTURAS DE MAYAGUEZ
MAYAGUEZ PR
00682
US

V. Phone/Fax

Practice location:
  • Phone: 787-832-0444
  • Fax:
Mailing address:
  • Phone: 787-672-1939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number15608
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: