Healthcare Provider Details

I. General information

NPI: 1821542234
Provider Name (Legal Business Name): PRIME OTOLARYNGOLOGY SERVICES, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 08/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 AVE F.D. ROOSEVELT MEZZANINE SUITE B
GUAYNABO PR
00968-2602
US

IV. Provider business mailing address

PO BOX 1036
GUAYNABO PR
00970-1036
US

V. Phone/Fax

Practice location:
  • Phone: 787-706-4334
  • Fax: 787-749-0993
Mailing address:
  • Phone: 787-706-4334
  • Fax: 787-749-0993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number11652
License Number StatePR

VIII. Authorized Official

Name: DR. LISETTE YVONNE PEREZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-706-4334