Provider Demographics
NPI:1306003207
Name:BONILLA, GABRIEL ANTONIO
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:ANTONIO
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 1:95 GRASSLANDS RD
Mailing Address - Street 2:
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-1652
Mailing Address - Country:US
Mailing Address - Phone:202-493-7693
Mailing Address - Fax:
Practice Address - Street 1:95 GRASSLANDS RD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1652
Practice Address - Country:US
Practice Address - Phone:202-493-7693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY263390207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program