Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 16664 | PR |
N | 207Q00000X | Family Doctor | MD041056 | DC |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 292251-1 | NY |
Y | 207QG0300X | Family Doctor - Geriatric Medicine | MD048978 | DC |
NPI | 1205039757 |
---|---|
Provider Name | Juan Samuel Ignacio Bonilla-Perez |
First Address | Washington, DC 20009-3602 |
Second Address | Washington, DC 20009-3602 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/06/2007 |
Last Update Date | 06/04/2021 |