Healthcare Provider Details

I. General information

NPI: 1487678736
Provider Name (Legal Business Name): PERSONAL HOME PHYSICIAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 02/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. 31 JUNCOS PLAZA LOCAL D-2
JUNCOS PR
00777
US

IV. Provider business mailing address

PO BOX 1221
JUNCOS PR
00777-1221
US

V. Phone/Fax

Practice location:
  • Phone: 787-713-6505
  • Fax: 787-713-6505
Mailing address:
  • Phone: 787-713-6505
  • Fax: 787-713-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15093
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15093
License Number StatePR

VIII. Authorized Official

Name: MR. IVAN R. RODRIGUEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-713-6505