Provider Demographics
NPI:1619169984
Name:BONILLA JACOME, CAROLINA (MD)
Entity type:Individual
Prefix:DR
First Name:CAROLINA
Middle Name:
Last Name:BONILLA JACOME
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLINA
Other - Middle Name:
Other - Last Name:BONILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5804 BABCOCK RD PMB 106
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-2134
Mailing Address - Country:US
Mailing Address - Phone:916-536-6030
Mailing Address - Fax:916-244-3865
Practice Address - Street 1:7400 MERTON MINTER ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-617-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1040772084P0800X
PAMT1917852084P0800X
TXP69522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABF777ZMedicare PIN