Provider Demographics
NPI:1114128725
Name:GONZALEZ-BONILLA, KEILAH ISABEL (MD)
Entity Type:Individual
Prefix:
First Name:KEILAH
Middle Name:ISABEL
Last Name:GONZALEZ-BONILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4623
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-4623
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:1811 LITTLE CREEK LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-6002
Practice Address - Country:US
Practice Address - Phone:865-690-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96511207Q00000X
TN45347207QG0300X, 207QH0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1521768Medicaid
TN1521768Medicaid