Provider Demographics
NPI:1053303289
Name:BONILLA DAVILA, JORGE L (OD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:BONILLA DAVILA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2053 PONCE BY PASS
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-1306
Mailing Address - Country:US
Mailing Address - Phone:787-848-2885
Mailing Address - Fax:787-848-4496
Practice Address - Street 1:2053 PONCE BY PASS
Practice Address - Street 2:SUITE 104
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1306
Practice Address - Country:US
Practice Address - Phone:787-848-2885
Practice Address - Fax:787-848-4496
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR149152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1053303289Medicaid
PR58049Medicare ID - Type Unspecified
PR1053303289Medicare NSC