Provider Demographics
NPI:1245317049
Name:PASTRANA BONILLA, VIVIAN (MD)
Entity type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:
Last Name:PASTRANA 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 1:1353 AVE LUIS VIGOREAUX
Mailing Address - Street 2:PMB 466
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-2715
Mailing Address - Country:US
Mailing Address - Phone:787-688-7924
Mailing Address - Fax:787-781-2116
Practice Address - Street 1:MENNONITE HOSPITAL INC.(CIMA)
Practice Address - Street 2:SARGENTO GERARDO SANTIAGO STREET, INTERIOR 14
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-735-6115
Practice Address - Fax:787-735-6190
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15304174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRI21446Medicare UPIN
PR0022803Medicare PIN