Provider Demographics
NPI:1619072949
Name:BOLANOS, GUILLERMO (MD)
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:
Last Name:BOLANOS
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:COSTA CARIBE GOLF VILLA
Mailing Address - Street 2:CALLE DON QUIJOTE 1249
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716
Mailing Address - Country:US
Mailing Address - Phone:787-841-1949
Mailing Address - Fax:787-812-0565
Practice Address - Street 1:909 AVE TITO CASTRO STE 723
Practice Address - Street 2:TORRE MEDICA SAN LUCAS
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-4725
Practice Address - Country:US
Practice Address - Phone:787-259-3355
Practice Address - Fax:787-259-3355
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR114602086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0088810Medicare ID - Type Unspecified
PRG40268Medicare UPIN