=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689389223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BONILLA GASTROENTEROLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2023
-----------------------------------------------------
Last Update Date | 01/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 187 AVE UNIVERSIDAD INTERAMERICANA, EDIFICIO RALI
-----------------------------------------------------
City | SAN GERMAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00683-0068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-215-6410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1387
-----------------------------------------------------
City | CABO ROJO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00623-1387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-215-6410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENTE
-----------------------------------------------------
Name | FERNANDO BONILLA VALENTIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-215-6410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------