Provider Demographics
NPI:1639573231
Name:GONZALEZ BONILLA, EDUARDO JOSE (MD)
Entity Type:Individual
Prefix:
First Name:EDUARDO
Middle Name:JOSE
Last Name:GONZALEZ 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:PO BOX 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:
Practice Address - Street 1:120 E BEAUREGARD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5919
Practice Address - Country:US
Practice Address - Phone:325-658-1511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-10
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS2786207R00000X
PR19034261QP2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8LMN32OtherBCBS
TX401122301Medicaid