1124075429 NPI number — JUDITH TERESA PALMER BENGOA MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124075429 NPI number — JUDITH TERESA PALMER BENGOA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PALMER BENGOA
Provider First Name:
JUDITH
Provider Middle Name:
TERESA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1124075429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
COND ST MARYS PLAZA
Provider Second Line Business Mailing Address:
TORRE SUR APT. 1601
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-530-0888
Provider Business Mailing Address Fax Number:
787-754-1059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
COND. ST. MARYS PLAZA
Provider Second Line Business Practice Location Address:
TORRE SUR , APT. 1601
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-530-0888
Provider Business Practice Location Address Fax Number:
787-754-1059
Provider Enumeration Date:
05/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  14006 , 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)





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