Provider Demographics
NPI:1841306255
Name:BELGODERE-BONILLA, JORGE RAFAEL (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:RAFAEL
Last Name:BELGODERE-BONILLA
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 1:811 ALBERTSON PKWY STE F
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-5256
Mailing Address - Country:US
Mailing Address - Phone:337-837-3615
Mailing Address - Fax:337-839-8097
Practice Address - Street 1:811 ALBERTSON PKWY STE F
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-5256
Practice Address - Country:US
Practice Address - Phone:337-837-3615
Practice Address - Fax:337-839-8097
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD025916207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CS48OtherMEDICARE
LA1545619Medicaid
H53012Medicare UPIN