Provider Demographics
NPI:1164609285
Name:BONILLA, GERALD
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name: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 1:5000 CHESHIRE LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-3706
Mailing Address - Country:US
Mailing Address - Phone:888-333-9152
Mailing Address - Fax:763-268-4240
Practice Address - Street 1:2320 DAIRY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-5208
Practice Address - Country:US
Practice Address - Phone:321-725-4948
Practice Address - Fax:321-725-0831
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS2624237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist