Provider Demographics
NPI:1619169984
Name:BONILLA JACOME, CAROLINA (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLINA
Middle Name:
Last Name:BONILLA JACOME
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLINA
Other - Middle Name:
Other - Last Name:BONILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-1267
Mailing Address - Country:US
Mailing Address - Phone:916-536-6030
Mailing Address - Fax:916-244-3865
Practice Address - Street 1:100 HOWE AVE STE 210S
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-8221
Practice Address - Country:US
Practice Address - Phone:916-536-6030
Practice Address - Fax:916-758-2139
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1917852084P0800X
TXP69522084P0800X
CAA1040772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABF777ZMedicare PIN