1548574635 NPI number — MEDICOS ESPECIALIZADOS DE SAN JUAN

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 1548574635 NPI number — MEDICOS ESPECIALIZADOS DE SAN JUAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICOS ESPECIALIZADOS DE SAN JUAN
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:
1548574635
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 16698
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00908-6698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
576 AVE CESAR GONZALEZ
Provider Second Line Business Practice Location Address:
STE 508
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-766-7070
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PORRATA
Authorized Official First Name:
ALEJANDRO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
787-420-9259

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  15828 , 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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