Provider Demographics
NPI:1629066006
Name:BONNEAUX, PHILLIP LEE (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:LEE
Last Name:BONNEAUX
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 21426
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00928-1426
Mailing Address - Country:US
Mailing Address - Phone:787-767-4010
Mailing Address - Fax:787-767-4010
Practice Address - Street 1:112 CALLE ARZUAGA
Practice Address - Street 2:STE 903
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925-3321
Practice Address - Country:US
Practice Address - Phone:787-767-4010
Practice Address - Fax:787-767-4010
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7366207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D95197Medicare UPIN