Provider Demographics
NPI:1215248364
Name:RIVERA-BONILLA, MARIA BELEN (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:BELEN
Last Name:RIVERA-BONILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3094
Mailing Address - Country:US
Mailing Address - Phone:863-293-1191
Mailing Address - Fax:
Practice Address - Street 1:199 AVENUE B NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4546
Practice Address - Country:US
Practice Address - Phone:863-293-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122431207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0156665700Medicaid
FLFR5533725OtherDEA