1902137698 NPI number — DR. ROEL ELFRIETH GARDESLEN MEDICINE

Table of content: DR. ROEL ELFRIETH GARDESLEN MEDICINE (NPI 1902137698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902137698 NPI number — DR. ROEL ELFRIETH GARDESLEN MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDESLEN
Provider First Name:
ROEL
Provider Middle Name:
ELFRIETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MEDICINE
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARDESLEN
Provider Other First Name:
ROEL
Provider Other Middle Name:
ELFRIETH
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MEDICINE
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1902137698
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
#5 URB.LAS FLORES J7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JUANA DIAZ
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00795
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-901-0815
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
#5 URB.LAS FLORES J7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JUANA DIAZ
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-901-0815
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/20/2010

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:  17716 , 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)