Provider Demographics
NPI:1669038329
Name:JORGE BONILLA MD PC
Entity Type:Organization
Organization Name:JORGE BONILLA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-608-4741
Mailing Address - Street 1:116 BROADWAY STE 1
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2797
Mailing Address - Country:US
Mailing Address - Phone:631-608-4741
Mailing Address - Fax:
Practice Address - Street 1:191 W HOFFMAN AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4036
Practice Address - Country:US
Practice Address - Phone:631-608-4741
Practice Address - Fax:631-608-4742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-17
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY264692OtherLICENSE