Provider Demographics
NPI:1750715868
Name:BONILLA BURGOS, ULISES (MD)
Entity type:Individual
Prefix:
First Name:ULISES
Middle Name:
Last Name:BONILLA BURGOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 STARR ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MERCEDES
Mailing Address - State:TX
Mailing Address - Zip Code:78570-2734
Mailing Address - Country:US
Mailing Address - Phone:956-903-4218
Mailing Address - Fax:956-903-4149
Practice Address - Street 1:208 STARR ST
Practice Address - Street 2:SUITE 3
Practice Address - City:MERCEDES
Practice Address - State:TX
Practice Address - Zip Code:78570-2734
Practice Address - Country:US
Practice Address - Phone:956-903-4218
Practice Address - Fax:956-903-4149
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-26
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9961193200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes193200000XGroupMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ9961OtherMEDICAL LICENSE TEXAS