Basic Information
| Provider Information | |||||||||
| NPI: | 1619072949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLANOS | ||||||||
| FirstName: | GUILLERMO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | COSTA CARIBE GOLF VILLA | ||||||||
| Address2: | CALLE DON QUIJOTE 1249 | ||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878411949 | ||||||||
| FaxNumber: | 7878120565 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 AVE TITO CASTRO STE 723 | ||||||||
| Address2: | TORRE MEDICA SAN LUCAS | ||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007164725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872593355 | ||||||||
| FaxNumber: | 7872593355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 02/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | 11460 | PR | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
No ID Information.