Healthcare Provider Details

I. General information

NPI: 1174353734
Provider Name (Legal Business Name): BORINQUEN UROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

METROPOLITAN OFFICE BUILDING 153 CALLE JOSE DE DIEGO
ARECIBO PR
00612
US

IV. Provider business mailing address

PO BOX 145200
ARECIBO PR
00614-5200
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-2891
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VICTOR E OTANO-RIVERA
Title or Position: UROLOGIST (CEO)
Credential: MD
Phone: 267-624-3578