Provider Demographics
NPI:1629180948
Name:BONILLA, BURKE J (MD)
Entity Type:Individual
Prefix:DR
First Name:BURKE
Middle Name:J
Last Name:BONILLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1060 W SIERRA AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-2063
Mailing Address - Country:US
Mailing Address - Phone:559-437-1111
Mailing Address - Fax:559-437-1118
Practice Address - Street 1:1060 W SIERRA AVE STE 105
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-2063
Practice Address - Country:US
Practice Address - Phone:559-437-1111
Practice Address - Fax:559-437-1118
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA635662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A635660Medicare PIN
CAH38285Medicare UPIN