Healthcare Provider Details

I. General information

NPI: 1124234471
Provider Name (Legal Business Name): ABDIAS JOEL DE LA ROSA SERRANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 10/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STREET 140 KM 56.3 BO. LA VAZQUEZ FLORIDA P.R 00650
FLORIDA PR
00650-0038
US

IV. Provider business mailing address

3381 PHILLIS BLVD
MYRTLE BEACH SC
29577-1560
US

V. Phone/Fax

Practice location:
  • Phone: 787-380-0775
  • Fax:
Mailing address:
  • Phone: 843-477-0177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16145
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: