Provider Demographics
NPI:1407854649
Name:BONILLA GONZALEZ, EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:BONILLA GONZALEZ
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:PO BOX 4952
Mailing Address - Street 2:PO BOX 4952
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-4952
Mailing Address - Country:US
Mailing Address - Phone:787-732-7424
Mailing Address - Fax:
Practice Address - Street 1:39 CALLE MUNOZ RIVERA
Practice Address - Street 2:CALLE MUNOZ RIVERA 39
Practice Address - City:AGUAS BUENAS
Practice Address - State:PR
Practice Address - Zip Code:00703-3233
Practice Address - Country:US
Practice Address - Phone:787-732-7424
Practice Address - Fax:787-732-7424
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11614208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
F94455Medicare UPIN
PR684792Medicare ID - Type Unspecified