Provider Demographics
NPI:1922106087
Name:BONILLA, MELISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name: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 1:69 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2114
Mailing Address - Country:US
Mailing Address - Phone:732-409-3633
Mailing Address - Fax:732-409-7133
Practice Address - Street 1:60 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728
Practice Address - Country:US
Practice Address - Phone:732-409-3633
Practice Address - Fax:732-409-7133
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233173208000000X
NJ25MA08165700208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0120995Medicaid