Provider Demographics
NPI:1134183379
Name:BERRIOS BONILLA, TAMARA (MD)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:BERRIOS 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:PO BOX 800851
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-0851
Mailing Address - Country:US
Mailing Address - Phone:787-971-7444
Mailing Address - Fax:787-515-7026
Practice Address - Street 1:URB. PORTAL DE LA REINA
Practice Address - Street 2:CALLE 4 SUITE #1
Practice Address - City:SANTA ISABEL
Practice Address - State:PR
Practice Address - Zip Code:00757
Practice Address - Country:US
Practice Address - Phone:787-971-7444
Practice Address - Fax:787-971-7230
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14003208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20762 ZOtherMEDICARE PTAN
H99566Medicare UPIN