Healthcare Provider Details

I. General information

NPI: 1538154315
Provider Name (Legal Business Name): ROBERTO LUIS DAVILA-DEPEDRO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 AVE ROOSVELET PLAZA LAS AMERICAS TOWER SUITE 712
HATO REY PR
00918-8001
US

IV. Provider business mailing address

PO BOX 191259
SAN JUAN PR
00919-1259
US

V. Phone/Fax

Practice location:
  • Phone: 787-764-6611
  • Fax: 787-754-1596
Mailing address:
  • Phone: 877-646-6117
  • Fax: 787-957-3110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number5154
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number5154
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number5154
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: