Healthcare Provider Details

I. General information

NPI: 1881449668
Provider Name (Legal Business Name): LUIS ERNESTO DE JESUS BURGOS DOCTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300C CALLE FONT MARTELO
HUMACAO PR
00791-3230
US

IV. Provider business mailing address

HC05BOX5452
YABUCOA PR
00767
US

V. Phone/Fax

Practice location:
  • Phone: 787-465-5603
  • Fax:
Mailing address:
  • Phone: 939-335-5478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number17921-I
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2072
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: