Provider Demographics
NPI:1215951934
Name:BONILLA, PEDRO (MD)
Entity type:Individual
Prefix:DR
First Name:PEDRO
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 1:163 GORE ST
Mailing Address - Street 2:EAST CAMBRIDGE HEALTH CENTER
Mailing Address - City:EAST CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02141-1119
Mailing Address - Country:US
Mailing Address - Phone:617-665-3000
Mailing Address - Fax:
Practice Address - Street 1:163 GORE ST
Practice Address - Street 2:EAST CAMBRIDGE HEALTH CENTER
Practice Address - City:EAST CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02141-1119
Practice Address - Country:US
Practice Address - Phone:617-665-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2272862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAI51699Medicare UPIN
MAA39740Medicare ID - Type Unspecified