Provider Demographics
NPI:1922040187
Name:IRIZARRY-BONILLA, MARISOL (MD)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:IRIZARRY-BONILLA
Suffix:
Gender:F
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:PLAZA DEL PARQUE
Mailing Address - Street 2:APT 346
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-3010
Mailing Address - Country:US
Mailing Address - Phone:787-760-5545
Mailing Address - Fax:787-760-5545
Practice Address - Street 1:CARR#181 KM.9.1 BO DOS BOCAS
Practice Address - Street 2:
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976
Practice Address - Country:UM
Practice Address - Phone:787-760-5545
Practice Address - Fax:787-760-5545
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15521208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1-42674Medicare UPIN
PR23279Medicare ID - Type UnspecifiedGENERAL PRACTICE