1184048175 NPI number — GLORIA PONCE TUA MEDICINA INTERNA CSP

Table of content: (NPI 1184048175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184048175 NPI number — GLORIA PONCE TUA MEDICINA INTERNA CSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLORIA PONCE TUA MEDICINA INTERNA CSP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184048175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CALLE DR BASORA NO 55N
Provider Second Line Business Mailing Address:
SUITE 204D
Provider Business Mailing Address City Name:
MAYAGUEZ
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00680-4888
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-833-0685
Provider Business Mailing Address Fax Number:
787-265-2755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CALLE DR BASORA NO 55N
Provider Second Line Business Practice Location Address:
SUITE 204D
Provider Business Practice Location Address City Name:
MAYAGUEZ
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00680-4888
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-833-0685
Provider Business Practice Location Address Fax Number:
787-265-2755
Provider Enumeration Date:
02/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
PONCE TUA
Authorized Official First Name:
GLORIA
Authorized Official Middle Name:
I
Authorized Official Title or Position:
MEDICO INTERNISTA
Authorized Official Telephone Number:
787-833-0685

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  13516 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1336189315 . This is a "NPI" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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