Provider Demographics
NPI:1629019708
Name:BONILLA, LUIS A (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
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 1:1580 VALENCIA ST
Mailing Address - Street 2:STE 803B
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4423
Mailing Address - Country:US
Mailing Address - Phone:415-285-7940
Mailing Address - Fax:
Practice Address - Street 1:1580 VALENCIA ST
Practice Address - Street 2:STE 803B
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-4423
Practice Address - Country:US
Practice Address - Phone:415-285-7940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01002352OtherMEDICARE RAILROAD
CA00A449111Medicaid
CA01002352OtherMEDICARE RAILROAD
CAE34151Medicare UPIN