Healthcare Provider Details

I. General information

NPI: 1356327274
Provider Name (Legal Business Name): EDWIN CAMILO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 CALLE PADRE SERCUS
AGUAS BUENAS PR
00703-3329
US

IV. Provider business mailing address

PADRE SERCU # 12
AGUAS BUENAS PR
00703
US

V. Phone/Fax

Practice location:
  • Phone: 787-732-0753
  • Fax: 787-732-2745
Mailing address:
  • Phone: 787-732-0753
  • Fax: 787-732-2745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number8473
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: