Provider Demographics
NPI:1376834176
Name:BONILLA, JORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:
Last Name:BONILLA
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 1:116 BROADWAY STE 1
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2797
Mailing Address - Country:US
Mailing Address - Phone:631-608-4741
Mailing Address - Fax:631-608-4742
Practice Address - Street 1:191 W HOFFMAN AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4036
Practice Address - Country:US
Practice Address - Phone:631-608-4741
Practice Address - Fax:631-608-4742
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264692207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04343519Medicaid
PRFE124AOtherMEDICARE PTAN