1407197395 NPI number — FERNANDO JAVIER CALERO BAQUERIZO MD

Table of content: (NPI 1952480691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407197395 NPI number — FERNANDO JAVIER CALERO BAQUERIZO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALERO BAQUERIZO
Provider First Name:
FERNANDO
Provider Middle Name:
JAVIER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1407197395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
78 BAKER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02905-4417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-484-5600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
78 BAKER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02905-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-781-2400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2013

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: 207R00000X , with the licence number:  MD17603 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD17603 . This is a "RI LICENSE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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