1679793905 NPI number — DR. LUIS E MORA-ANTONGIORGI OD

Table of content: DR. LUIS E MORA-ANTONGIORGI OD (NPI 1679793905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679793905 NPI number — DR. LUIS E MORA-ANTONGIORGI OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORA-ANTONGIORGI
Provider First Name:
LUIS
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1679793905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
576 AVE ARTERIAL B APT 2309
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:
00918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-892-1218
Provider Business Mailing Address Fax Number:
787-892-7480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 AVE ROOSEVELT
Provider Second Line Business Practice Location Address:
PLAZA LAS AMERICAS LENSCRAFTERS 0474
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:
787-753-6431
Provider Business Practice Location Address Fax Number:
787-753-0852
Provider Enumeration Date:
04/27/2007

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: 152W00000X , with the licence number:  403-0029 , 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: 038172400 , issued by the state of ( PR ) . This identifiers is of the category "MEDICAID".




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