Healthcare Provider Details

I. General information

NPI: 1326745571
Provider Name (Legal Business Name): DERMATOLOGIA BORINQUEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2023
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 AVENIDA GAUTIER BENITEZ CONSOLIDATED MEDICAL PLAZA (OFFICE 405A)
CAGUAS PR
00725
US

IV. Provider business mailing address

PO BOX 6106
CAGUAS PR
00726-6106
US

V. Phone/Fax

Practice location:
  • Phone: 787-246-3376
  • Fax: 939-355-0306
Mailing address:
  • Phone: 787-246-3376
  • Fax: 939-355-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: JESUS CRUZ RODRIGUEZ
Title or Position: ADMINISTRATOR
Credential: MD, PA
Phone: 787-246-3376