=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144206871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ILEANA RIVERA BONILLA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2005
-----------------------------------------------------
Last Update Date | 11/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | VILLAS DE SAN AGUSTIN CALLE 2 A 13
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-786-5844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | A3 AVE PEREZ ANDINO URB VILLAS DE RIO GRANDE
-----------------------------------------------------
City | RIO GRANDE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-888-2302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 10742
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------