Healthcare Provider Details

I. General information

NPI: 1114915907
Provider Name (Legal Business Name): ANGEL R EGOZCUE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 111 K 2.0
LARES PR
00669
US

IV. Provider business mailing address

PO BOX 1455
LARES PR
00669-1455
US

V. Phone/Fax

Practice location:
  • Phone: 787-647-1828
  • Fax: 787-897-6728
Mailing address:
  • Phone: 787-647-1828
  • Fax: 787-897-6728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number00372
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: