1215032057 NPI number — DR. ELLIOTT BERMUDEZ-COLON DDS

Table of content: DR. ELLIOTT BERMUDEZ-COLON DDS (NPI 1215032057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215032057 NPI number — DR. ELLIOTT BERMUDEZ-COLON DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERMUDEZ-COLON
Provider First Name:
ELLIOTT
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1215032057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8322 MOJAVE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78254-2139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-643-0070
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2940 STANLEY RD STE 2375
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SAM HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78234-2740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-295-4595
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2006

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: 122300000X , with the licence number:  2118 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0300X , with the licence number: 2118 , 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)