Provider Demographics
NPI:1336854314
Name:BONILLA, JOSE ANGEL
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ANGEL
Last Name:BONILLA
Suffix:
Gender:M
Credentials:
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 609
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-0609
Mailing Address - Country:US
Mailing Address - Phone:787-629-9150
Mailing Address - Fax:
Practice Address - Street 1:327 CALLE BROADWAY
Practice Address - Street 2:
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-4658
Practice Address - Country:US
Practice Address - Phone:787-629-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR251K00000X
PR23655208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No251K00000XAgenciesPublic Health or Welfare