Provider Demographics
NPI:1053993949
Name:BONILLA, DAVID HERRERA
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:HERRERA
Last Name:BONILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 WEDGEMONT PL
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-2964
Mailing Address - Country:US
Mailing Address - Phone:661-330-1385
Mailing Address - Fax:
Practice Address - Street 1:2100 WEDGEMONT PL
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-2964
Practice Address - Country:US
Practice Address - Phone:661-330-1385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN3637331172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty