MEDICARE: CENTRO MEDICO SAN JOSE CSP

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	208000000X	Pediatrics Physician	10574	PR

General Provider Information

NPI Number	:	1356325930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRO MEDICO SAN JOSE CSP

Provider Business Mailing Address
First Line	:	C/A IHAMBRD 4 #8 URB TORRIMAR
Second Line	:
City	:	GUAYNABO
State	:	PR
Zip	:	00966
Country	:	US
Telephone Number	:	787-785-5592
Fax Number	:	787-785-5593

Provider Business Practice Location Address
First Line	:	CALLE MARGINAL
Second Line	:	URB SANTA CRUZ
City	:	BAYAMON
State	:	PR
Zip	:	00957-2536
Country	:	US
Telephone Number	:	787-785-5592
Fax Number	:	787-785-5593

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOSE S IGUINA
Credential	:	MD
Telephone Number	:	787-785-5592

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	08/22/2020

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