Healthcare Provider Details

I. General information

NPI: 1164525465
Provider Name (Legal Business Name): SAMUEL NEGRON AGOSTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE CIPRES #706 LOCAL #2 FAJARDO GARDENS
FAJARDO PR
00738
US

IV. Provider business mailing address

PO BOX 1666
FAJARDO PR
00738-1666
US

V. Phone/Fax

Practice location:
  • Phone: 787-801-4698
  • Fax: 787-801-4698
Mailing address:
  • Phone: 787-801-4698
  • Fax: 787-801-4698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number11991
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: