Healthcare Provider Details

I. General information

NPI: 1437366531
Provider Name (Legal Business Name): ENEROLISA ALTAGRACIA CORDERO-POLANCO M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE. ROBERTO CLEMENTE BLOQ 132 # 11 VILLA CAROLINA
CAROLINA PR
00985
US

IV. Provider business mailing address

PO BOX 1205
CEIBA PR
00735-1205
US

V. Phone/Fax

Practice location:
  • Phone: 178-727-6428
  • Fax:
Mailing address:
  • Phone: 178-727-6428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number16133
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: