Provider Demographics
NPI:1134602014
Name:GALLOZA BONILLA, CORALYS (OD)
Entity type:Individual
Prefix:
First Name:CORALYS
Middle Name:
Last Name:GALLOZA BONILLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 SW 67TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-4761
Mailing Address - Country:US
Mailing Address - Phone:787-207-4529
Mailing Address - Fax:
Practice Address - Street 1:920 SW 67TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-4761
Practice Address - Country:US
Practice Address - Phone:787-207-4529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5590152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist