Provider Demographics
NPI:1649705492
Name:BONILLA, MAGGIE M (DO)
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:M
Last Name:BONILLA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MAGGIE
Other - Middle Name:
Other - Last Name:GERK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:208-642-9598
Practice Address - Street 1:840 SW 4TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2638
Practice Address - Country:US
Practice Address - Phone:541-881-2800
Practice Address - Fax:541-881-2825
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14735A208000000X
ORDO219284207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics