Healthcare Provider Details

I. General information

NPI: 1740300839
Provider Name (Legal Business Name): IDAMAR LAUREANO LANDRON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LOTE 1METRO OFFICE PARK SUITE 400
GUAYNABO PR
00968
US

IV. Provider business mailing address

39 STREET SANTA JUANITA PMB 334 UU1
BAYAMON PR
00956
US

V. Phone/Fax

Practice location:
  • Phone: 787-774-3344
  • Fax: 787-774-6251
Mailing address:
  • Phone: 787-396-7423
  • Fax: 787-288-1115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11704
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: