Healthcare Provider Details

I. General information

NPI: 1609889229
Provider Name (Legal Business Name): CARLOS IVAN MALDONADO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE LUIS MUNOZ RIVERA FINAL
JUNCOS PR
00777
US

IV. Provider business mailing address

76 TWILIGHT ST SUNRISE AT PALMAS
HUMACAO PR
00791-6305
US

V. Phone/Fax

Practice location:
  • Phone: 787-734-2737
  • Fax: 787-734-2737
Mailing address:
  • Phone: 787-638-0064
  • Fax: 787-734-2737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number15122
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15122
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: