Healthcare Provider Details

I. General information

NPI: 1386928349
Provider Name (Legal Business Name): CDT HORMIGUEROS PREVENTIVE MEDICINE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 10/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STREET 2 ,MUNOZ MARIN CDT HORMIGUEROS
HORMIGUEROS PR
00660
US

IV. Provider business mailing address

PO BOX 1550
HORMIGUEROS PR
00660-5550
US

V. Phone/Fax

Practice location:
  • Phone: 787-382-2583
  • Fax:
Mailing address:
  • Phone: 787-484-8273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JIMMY OLIVERA
Title or Position: ADMINISTRATOR
Credential:
Phone: 787-484-8273