Provider Demographics
NPI:1023080744
Name:BONILLA, GABRIEL L (MD)
Entity type:Individual
Prefix:DR
First Name:GABRIEL
Middle Name:L
Last Name: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 1:2526 W RANCHO LAREDO DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-7168
Mailing Address - Country:US
Mailing Address - Phone:928-600-6762
Mailing Address - Fax:
Practice Address - Street 1:2526 W RANCHO LAREDO DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-7168
Practice Address - Country:US
Practice Address - Phone:928-600-6762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32912208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ862913Medicaid
AZZ171892Medicare PIN
AZI08385Medicare UPIN