Provider Demographics
NPI:1134575111
Name:BONILLA DIAZ, GLADYMAR (MD)
Entity type:Individual
Prefix:
First Name:GLADYMAR
Middle Name:
Last Name:BONILLA DIAZ
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:A-13 CALLE 1
Mailing Address - Street 2:URB RIO GRANDE ESTATE
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:A-13 CALLE 1
Practice Address - Street 2:URB RIO GRANDE ESTATE
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745
Practice Address - Country:US
Practice Address - Phone:787-647-0729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004651246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other