Provider Demographics
NPI:1467082958
Name:BONILLA, JOHNNY (DPT)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:BONILLA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 PATCHOGUE YAPHANK RD
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4899
Mailing Address - Country:US
Mailing Address - Phone:516-551-4722
Mailing Address - Fax:631-475-0975
Practice Address - Street 1:191 PATCHOGUE YAPHANK RD
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4899
Practice Address - Country:US
Practice Address - Phone:516-551-4722
Practice Address - Fax:631-475-0975
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045343-01208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY045343-01OtherNYS PT LICENSE