Healthcare Provider Details

I. General information

NPI: 1538578190
Provider Name (Legal Business Name): LUISA FERNANDA ANGEL BUITRAGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 11/18/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BARRIO MONTELLANO CARR 14 KM 72
CAYEY PR
00736
US

IV. Provider business mailing address

PO BOX 373206
CAYEY PR
00737-3206
US

V. Phone/Fax

Practice location:
  • Phone: 939-419-8866
  • Fax:
Mailing address:
  • Phone: 787-460-9225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31481R
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number19494
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number19494
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: