Healthcare Provider Details

I. General information

NPI: 1063914729
Provider Name (Legal Business Name): SAN LAZARGERD MEDICAL II CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 129 KM 21.2 BO CALLEJONES
LARES PR
00669
US

IV. Provider business mailing address

PO BOX 428
LARES PR
00669-0428
US

V. Phone/Fax

Practice location:
  • Phone: 787-897-0353
  • Fax:
Mailing address:
  • Phone: 787-897-0353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number StatePR
# 4
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number
License Number StatePR

VIII. Authorized Official

Name: GERALDO GONZALEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 787-897-0560