Provider Demographics
NPI:1154301265
Name:BONILLA, LUIS A (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:A
Last Name:BONILLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:425 CARR 693
Mailing Address - Street 2:PMB 121
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-4802
Mailing Address - Country:US
Mailing Address - Phone:787-366-6445
Mailing Address - Fax:787-854-3440
Practice Address - Street 1:CARR #2 KM 47.7
Practice Address - Street 2:DOCTOR'S CENTER HOSPITAL
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-363-2744
Practice Address - Fax:787-854-3440
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD426722208600000X
PR17529208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014293760003Medicaid
146815Medicare UPIN
096597Medicare ID - Type Unspecified