Provider Demographics
NPI:1316186943
Name:IN HIS IMAGE MEDICAL, INC
Entity Type:Organization
Organization Name:IN HIS IMAGE MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:RCS, CVT
Authorized Official - Phone:305-345-2055
Mailing Address - Street 1:16510 SW 96TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-5832
Mailing Address - Country:US
Mailing Address - Phone:305-345-2055
Mailing Address - Fax:305-388-3182
Practice Address - Street 1:13550 SW 88TH ST STE 180
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-1513
Practice Address - Country:US
Practice Address - Phone:305-381-2868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00069740261QR0208X, 261QR0208X
FLME56235207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MobileGroup - Single Specialty