1063585024 NPI number — MARISOL M MUBARAK PERDOMO M.D.

Table of content: MARISOL M MUBARAK PERDOMO M.D. (NPI 1063585024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063585024 NPI number — MARISOL M MUBARAK PERDOMO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUBARAK PERDOMO
Provider First Name:
MARISOL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1063585024
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CALLE BIENTEVEO NUM 94
Provider Second Line Business Mailing Address:
MONTEHIEDRA
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-724-8945
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1451 AVE ASHFORD ESQ NAIRM
Provider Second Line Business Practice Location Address:
ESTACIONAMIENTO LA GALERIA SUITE 611
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00907-1567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-724-8945
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2006

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: 2084N0400X , with the licence number:  11177 , 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)

  • Identifier: 217023 . This is a "PREFERRED HEALTH" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 0500133 . This is a "HUMANA HEALTH PLANS" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 600108 . This is a "MEDICARE Y MUCHO MAS" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 83360 . This is a "TRIPLE S" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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