Provider Demographics
NPI:1801424866
Name:BONILLA, MAURICIO (MD)
Entity type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name: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 1:452 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-3446
Mailing Address - Country:US
Mailing Address - Phone:909-450-9208
Mailing Address - Fax:
Practice Address - Street 1:1129 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-1703
Practice Address - Country:US
Practice Address - Phone:909-363-9300
Practice Address - Fax:562-690-3182
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA186367207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program