Healthcare Provider Details

I. General information

NPI: 1194110528
Provider Name (Legal Business Name): JUAN M PUERTAS D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

7825 SW 165TH ST
PALMETTO BAY FL
33157-3742
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-5230
  • Fax:
Mailing address:
  • Phone: 614-401-7470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS17386
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: