Healthcare Provider Details

I. General information

NPI: 1700500063
Provider Name (Legal Business Name): EG PEDS GASTRO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2022
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BAYAMON MEDICAL PLAZA PR WOMEN'S AND CHILDREN'S HOSPITAL CARR 2 KM 11.7
BAYAMON PR
00959
US

IV. Provider business mailing address

PO BOX 193307
SAN JUAN PR
00919-3307
US

V. Phone/Fax

Practice location:
  • Phone: 787-466-8762
  • Fax:
Mailing address:
  • Phone: 787-466-8762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: ESTHERMARI GONZALEZ POLANCO
Title or Position: PRESIDENT
Credential: MD
Phone: 787-407-7569