Provider Demographics
NPI:1902921364
Name:MELENDEZ- BONILLA, JORGE (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:MELENDEZ- 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:PO BOX 11636
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00922-1636
Mailing Address - Country:US
Mailing Address - Phone:787-616-3459
Mailing Address - Fax:787-793-8487
Practice Address - Street 1:435 AVE PONCE DE LEON
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-3428
Practice Address - Country:US
Practice Address - Phone:787-616-3459
Practice Address - Fax:787-793-8487
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3840207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0063529OtherLA CRUZ AZUL DE PR
PR95189OtherTRIPLE S
PR0063529OtherLA CRUZ AZUL DE PR
PR95189OtherTRIPLE S