Provider Demographics
NPI:1013177013
Name:BONILLA, JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BONILLA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5224 75TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-2525
Mailing Address - Country:US
Mailing Address - Phone:806-712-1096
Mailing Address - Fax:806-771-2093
Practice Address - Street 1:1255 ASHBY ST STE A
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5100
Practice Address - Country:US
Practice Address - Phone:830-590-8049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.204149207RI0011X
390200000X
TXU5573207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1105023Medicaid
MS03208741Medicaid
LA417775YH3UMedicare PIN