Healthcare Provider Details

I. General information

NPI: 1558341487
Provider Name (Legal Business Name): ROSE EILEEN JUSTINIANO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 CALLE 65 INFANTERIA SUITE A-109
ANASCO PR
00610-2909
US

IV. Provider business mailing address

19 CALLE BIMINI
MAYAGUEZ PR
00680-5120
US

V. Phone/Fax

Practice location:
  • Phone: 787-826-2145
  • Fax:
Mailing address:
  • Phone: 787-823-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15,674
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: