Provider Demographics
NPI:1548516008
Name:PEDRO J. BONILLA, MD PC
Entity type:Organization
Organization Name:PEDRO J. BONILLA, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-696-9035
Mailing Address - Street 1:1415 BEACON ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-4816
Mailing Address - Country:US
Mailing Address - Phone:617-933-8130
Mailing Address - Fax:
Practice Address - Street 1:1415 BEACON ST
Practice Address - Street 2:SUITE 320
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-4816
Practice Address - Country:US
Practice Address - Phone:617-933-8130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-01
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA39740 MAMedicare PIN
MAI51699 MAMedicare UPIN