Provider Demographics
NPI:1174227425
Name:BONILLA, FLAVIO FERNANDO (MD, MS)
Entity type:Individual
Prefix:
First Name:FLAVIO
Middle Name:FERNANDO
Last Name:BONILLA
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 W 12TH AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1267
Mailing Address - Country:US
Mailing Address - Phone:614-293-3989
Mailing Address - Fax:614-293-9789
Practice Address - Street 1:395 W 12TH AVE FL 3
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1267
Practice Address - Country:US
Practice Address - Phone:614-293-3989
Practice Address - Fax:614-293-9789
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH57.254825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program