Provider Demographics
NPI:1609873736
Name:BONILLA, MARIO A (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:A
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 1:5012 S US HIGHWAY 75 STE 300
Mailing Address - Street 2:ATTN BILLING
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4589
Mailing Address - Country:US
Mailing Address - Phone:903-465-3624
Mailing Address - Fax:903-465-3973
Practice Address - Street 1:5026 POOL ROAD
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4595
Practice Address - Country:US
Practice Address - Phone:903-465-3624
Practice Address - Fax:903-465-3973
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF5839207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK12480OtherMEDICAL LICENSE
OK100041710AMedicaid
TX132567208Medicaid
TX132567208Medicaid
OK12480OtherMEDICAL LICENSE
TX387608YSYFMedicare PIN