Provider Demographics
NPI:1467497792
Name:BONILLA, CLAUDINA A (MD)
Entity type:Individual
Prefix:DR
First Name:CLAUDINA
Middle Name:A
Last Name:BONILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CLAUDIA
Other - Middle Name:
Other - Last Name:BONILLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 547771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32854-7771
Mailing Address - Country:US
Mailing Address - Phone:407-883-0655
Mailing Address - Fax:
Practice Address - Street 1:301 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:407-883-0655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069669207RP1001X
FLME069669207RC0200X
GA040321207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379271400Medicaid
E50466Medicare UPIN
FL379271400Medicaid
E50466Medicare UPIN