Healthcare Provider Details

I. General information

NPI: 1356325930
Provider Name (Legal Business Name): CENTRO MEDICO SAN JOSE CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE MARGINAL URB SANTA CRUZ
BAYAMON PR
00957-2536
US

IV. Provider business mailing address

C/A IHAMBRD 4 #8 URB TORRIMAR
GUAYNABO PR
00966
US

V. Phone/Fax

Practice location:
  • Phone: 787-785-5592
  • Fax: 787-785-5593
Mailing address:
  • Phone: 787-785-5592
  • Fax: 787-785-5593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10574
License Number StatePR

VIII. Authorized Official

Name: MR. JOSE S IGUINA
Title or Position: PRESIDENT
Credential: MD
Phone: 787-785-5592