Provider Demographics
NPI:1235803586
Name:BONILLA BENITEZ, SEBASTIAN ALEXIS (MD)
Entity Type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:ALEXIS
Last Name:BONILLA BENITEZ
Suffix:
Gender:M
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:URB VEVE CALZADA CALLE 3A O28
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738
Mailing Address - Country:US
Mailing Address - Phone:787-602-2923
Mailing Address - Fax:
Practice Address - Street 1:404 AVE GENERAL VALERO
Practice Address - Street 2:
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-3998
Practice Address - Country:US
Practice Address - Phone:787-655-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR23372208D00000X
PR16235-I390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice