1083776397 NPI number — DR. LUIS A FRAGUADA-VEGA DMD

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 1083776397 NPI number — DR. LUIS A FRAGUADA-VEGA DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRAGUADA-VEGA
Provider First Name:
LUIS
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
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:
1083776397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 363861
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:
00936-3861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-745-2130
Provider Business Mailing Address Fax Number:
787-745-2130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
B28 CALLE CORAZON
Provider Second Line Business Practice Location Address:
VILLA CRIOLLOS
Provider Business Practice Location Address City Name:
CAGUAS
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00725-4037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-745-2130
Provider Business Practice Location Address Fax Number:
787-745-2130
Provider Enumeration Date:
12/14/2006

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:  2763 , 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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