Provider Demographics
NPI:1093161556
Name:GAUDINO BONILLA, WILFREDO
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:GAUDINO BONILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:H30 CALLE COQUI DORADO
Mailing Address - Street 2:MANSIONES MONTE VERDE
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00736
Mailing Address - Country:US
Mailing Address - Phone:939-335-9115
Mailing Address - Fax:
Practice Address - Street 1:H30 CALLE COQUI DORADO
Practice Address - Street 2:MANSIONES MONTE VERDE
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736
Practice Address - Country:US
Practice Address - Phone:939-335-9115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1222156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician