MEDICARE: CENTRO MEDICO IBEROAMERICANO INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician		NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1055488	OTHER	HORIZON NJ HEALTH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	F73229	OTHER	UPIN

General Provider Information

NPI Number	:	1255520482
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO MEDICO IBEROAMERICANO INC.

Provider Business Mailing Address
First Line	:	416 PARK AVE
Second Line	:
City	:	PATERSON
State	:	NJ
Zip	:	07504-1930
Country	:	US
Telephone Number	:	973-684-8138
Fax Number	:	973-684-0032

Provider Business Practice Location Address
First Line	:	416 PARK AVE
Second Line	:
City	:	PATERSON
State	:	NJ
Zip	:	07504-1930
Country	:	US
Telephone Number	:	973-684-8138
Fax Number	:	973-684-0032

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RAMON ANTONIO SANDOVAL
Credential	:	M.D.
Telephone Number	:	973-684-8138

Provider Enumeration Date	:	10/24/2007
Last Update Date	:	12/19/2011

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