Healthcare Provider Details

I. General information

NPI: 1760467922
Provider Name (Legal Business Name): DR. BOLIVAR BURGOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110E AVE FONT MARTELO
HUMACAO PR
00791-3928
US

IV. Provider business mailing address

PO BOX 313 110E FONT MARTELO ST.
HUMACAO PR
00792-0313
US

V. Phone/Fax

Practice location:
  • Phone: 787-852-5568
  • Fax: 787-852-5568
Mailing address:
  • Phone: 787-852-5568
  • Fax: 787-852-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number5730
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: